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A   TREATISE 


ON 


ORTHOPEDIC  SURGERY 


BY 

ROYAL    WHITMAN,    M.D. 

Instructor  in  Oethop.'edic  Surgery  and  Chief  of  the  Orthopedic  Department  of  the 

Vandekbilt  Clinic  in   the   College  of  Physicians  and  Surgeons  of  Columbia 

University  ;  Adjunct  Professor  of  Orthop.edic  Surgery'  in  the  New 

York  Polyclinic;  Assistant  Surgeon  and  Chief  of  Clinic 

AT  the  Hospital  for  Ruptured  and  Crippled; 

Orthop.edic  Surgeon  to  the  Hospital 

OF  St.  John's  Guild. 

Member  of  the  Royal  College  of  Surgeons  of  England;    Member  and    Sometime    President 

OF  the  American  Orthopedic  Association  ;    Corresponding  JIe.mber  of  the  British 

ORTHOP.iEDic  Society  ;  Member  of  the  New  York  Surgical  Society-,  Ktc. 


ILLUSTRATED    WITH    FOUR    HUNDRED    AND    FORTY-SEVEN 

ENGRAVINGS 


LEA     BROTHERS     &     CO. 
PHILADELPHIA     AND     NEW     YOKE 


Entered  according  to  the  Act  of  Congress  in  the  vear  1901,  bv 
LEA  BEOTHEES   &  CO. 

In  the  Office  of  the  Librarian  of  Congress.     All  rights  reserved. 


TO 
VIRGIL  P.  GIBNEY,  M.D.,  LL.D. 

This  Volume  is  Inscribed 

AS  A  Token  of  Friendship  Assured  by  Long  Association, 

AND  OF  Appreciation  of  His  Efforts 

for  the  Advancement  of 

ORTHOPEDIC   SURGEEY 


'37480- 


2* 


PREFACE. 


The  student  of  Orthopaedic  Surgery  is  especially  concerned  with 
the  mechanics  of  the  human  machine,  with  its  development,  with  its 
capacity  at  different  periods  of  life  and  under  varying  conditions,  and 
with  those  affections  that  lead  to  deformity  or  that  otherwise  impair 
its  usefulness.  He  is  concerned,  moreover,  not  only  with  the  local 
and  immediate  effects  of  disease  or  disability,  but  with  its  general  in- 
fluence upon  the  entire  mechanism,  and  with  its  ultimate  consequences 
as  well. 

Orthopsedic  Surgery  occupies  a  broad  field  and  one  of  very  great 
and  general  interest.  Its  most  distinctive  advance  in  recent  years  has 
been  toward  the  prevention  of  deformity,  an  advance  that  has  been 
made  possible  by  the  better  understanding  of  its  predisposing  and  ex- 
citing causes.  As  a  natural  consequence,  treatment  has  become  more 
direct,  more  simple,  and  more  effective.  It  has  been  the  purpose  of 
the  author  to  emphasize  this  aspect  of  the  subject,  which  is  of  the 
greatest  importance  to  the  general  practitioner,  who  so  often  has  the 
opportunity  to  recognize  disease  or  disability  in  its  incipiency,  when  its 
progress  may  be  checked  by  timely  treatment. 

He  has  endeavored  to  present  Orthopaedic  Surgery  as  far  as  pos- 
sible objectively,  and  in  a  manner  that  has  proved  acceptable  to  stu- 
dents and  practitioners  in  clinical  teaching.  Thus  the  selection  of 
each  subject  and  the  space  that  has  been  allotted  to  it  has  been  deter- 
mined primarily  by  its  relative  importance  in  the  actual  work  of  Or- 
thopaedic clinics.  He  has  been  at  some  pains,  also,  to  outline  methods 
of  examination,  to  explain  the  phenomena  of  the  symptoms  and  so  to 
describe  and  to  illustrate  the  causes  and  effects  of  disease  and  disability 
as  to  indicate,  in  natural  sequence,  the  principles  of  treatment ;  but 
the  particular  methods  of  the  application  of  these  principles,  which 
have  been  described  in  detail,  are  always  those  that  have  been  tested 
by  personal  experience. 

Although  this  book  is  designed  particularly  for  students  and  practi- 
tioners of  medicine,  the  author  has  included  statistical  and  other  data 


VI  PREFACE. 

which  he  hopes  may  prove  of  interest  to  his  fellow-workers  in  this 
special  field. 

The  author  desires  to  express  his  obligation  to  the  gentlemen  who 
have  assisted  him  in  the  collection  of  statistics,  and  otherwise,  whose 
names  are  mentioned  in  the  text ;  to  Dr.  L.  W.  Ely  and  to  Mr.  W.  P. 
Agnew  for  timely  photographs,  and  especially  to  the  Trustees  of  the 
Hospital  for  Ruptured  and  Crippled,  for  the  facilities  that  have  been 
afforded  him  in  the  preparation  of  this  work. 

New  York,  February,  1901. 


CONTENTS. 


CHAPTER   I. 

TUBERCULOUS    DISEASE    OF    THE    SPINE. 

Description  —  Pathology —  Etiology —  Statistics  —  General  prognosis  — 
Symptoms — Physical  examination — Contour  and  flexibility  of  the 
spine — ^Divisions  of  the  spine — Landmarks — The  differential  diagno- 
sis of  disease  in  the  lower,  middle  and  upper  regions  of  the  spine — 
Treatment  by  horizontal  fixation — by  braces — by  jackets — by  other 
means.  The  selection  and  adaptation  of  treatment  for  disease  of  the 
different  regions  of  the  spine.  The  complications  of  tuberculous 
disease  of  the  spine — Abscess — course  —  symptoms  —  treatment. 
Paralysis — course — symptoms — treatment.  Forcible  correction  of 
deformity — (Calot's  operation) — Gradual  correction  of  deformity...     17 

CHAPTER    II. 

NON-TUBERCULOUS    AFFECTIONS    OF    THE    SPINE. 

Syphilis — Malignant  disease — Osteomyelitis — Actinomycosis — Inj  ury — 
Traumatic  spondylitis — Ehachitic  spine — Typhoid  spine — Gonor- 
rhoeal  "rheumatism"  of  the  spine — Arthritis — Spondylitis  defor- 
tnans— Osteitis  deformans — Neurotic  spine — Hysterical  spine  — 
Spondylolisthesis — Sciatic  scoliosis — Sacro-iliac  disease 107 

CHAPTER   III. 

LATERAL   CURVATURE    OF   THE    SPINE. 

Description — habitual  and  fixed  deformity,  rotation  and  lateral  devia- 
tion. Pathology —  Etiology —  Statistics  — Varieties  —  Distribution 
and  effects  of  deformity — ^Symptoms — Diagnosis — Prognosis-^Pre- 
vention  of  deformity— Treatment — by  exercises — general  exercises 
— heavy  exercises — special  exercises — Supports.  Forcible  correc- 
tion of  deformity — Adjuncts  in  treatment — Duration  of  treatment..  120 

CHAPTER    IV. 

DEFORMITIES    OF    THE    SPINE,    CONTINUED.       DEFORMITIES     OF    THE 
CHEST.       FUNCTIONAL    PATHOGENESIS    OF    DEFORMITY. 

Varieties  in  contour  of  the  spine — Kyphosis — Lordosis — Congenital  ele- 
vation of  the  scapula — Absence  of  vertebrae — Flat  chest — Pigeon 


viii  CONTENTS. 

chest — Funnel  chest — Absence  of  ribs — Defective  formation  of  the 
pectoral  muscles — Absence  or  defect  of  the  clavicle — Acquired  lux- 
ation or  subluxation  of  the  clavicle — Asymmetrical  development — 
Tables  of  height,  weight,  and  circumference  of  the  chest — Func- 
tional pathogenesis  of  deformity — (Wolff's  law) 181 

CHAPTER  V. 

TUBERCULOUS    DISEASE    OF    THE    BOXES    AND    JOINTS. 

Predisposition — Mode  of  infection — Latent  tuberculosis — Local  predis- 
position— Statistics — distribution  of  disease — location — side  affected 
— sex — age.  Pathology — Varieties  of  disease — Method  of  repair — 
Prognosis — Treatment — operative  and  mechanical — by  drugs — local 
applications — venous  stasis  (Bier's  treatment) 194 

CHAPTER  VI. 

NON-TUBERCULOUS    DISEASES    OF    THE    JOINTS. 

Syphilitic  disease  of  joints — Gonorrhoeal  arthritis — Other  forms  of  in- 
fectious arthritis — Acute  epiphj^sitis — Localized  infectious  osteo- 
myelitis— Osteo- arthritis — Haemophilia  —  Hsemarthrosis  —  Scorbu- 
tus— Charcot' s  disease — Anchylosis 206 

CHAPTER   VII. 

TUBERCULOUS    DISEASE    OF    THE    HIP    JOINT. 

"Pathology — Statistics — Symptoms — Physical  signs,  distortion,  apparent 
lengthening,  apparent  shortening.  Causes  of  distortion — Atrophy — 
Causes  of  actual  shortening — Measurements — Lovett' stable — Kings- 
ley's  table — Differential  diagnosis — Principles  of  treatment — The 
traction  hip  brace — The  Thomas  brace — The  plaster  bandage — Vari- 
ous methods  of  reducing  deformity — The  long  hip  splint — Other 
forms  of  apparatus — Double  hip  disease — Abscess — statistics — treat- 
ment— Operative  treatment — exjjloration — excision — reduction  of 
resistant  deformity — Prognosis,  mortality,  functional  results.  Sec- 
ondary deformities  of  hip  disease — Final  results 221 

CHAPTER   VIII. 

NON-TUBERCULOUS    AFFECTIONS    OF    THE    HIP    JOINT. 

Traumatisms  at  the  hip — Acute  infectious  arthritis — Extra-articular  dis- 
ease— Malignant  disease  at  the  hip  joint — Cysts  of  the  femur — Ar- 
thritis deformans 300 

CHAPTER   IX. 

TUBERCULOUS   DISEASE   OF   THE    KNEE   JOINT. 

Pathology — Etiology — Statistics — Symptoms, primary  and  secondary  dis- 
tortions— Diagnosis — Differential    diagnosis — Treatment — mechan- 


CONTENTS.  ix 

ical  —  Extra-articular  disease — Abscess  —  Operative  treatment — 
arthreetomy — excision,  amputation — Prognosis — mortality — func- 
tional results — General  conclusions 304 

CHAPTER   X. 

NON-TUBEECULOUS    AFFECTIONS    OF    THE    KNEE    JOINT. 

Injury  in  childhood — Synovitis — Infectious  arthritis — Osteo-arthritis — 
Prepatellar  bursitis — Pretibial  bursitis — Bursse  and  cysts  in  the 
popliteal  region — Internal  derangement  of  the  knee  joint — Con- 
genital genu  recurvatum — rudimentary  or  absent  patella — Con- 
genital displacement  of  patella — Slipping  patella — Elongation  of  the 
ligamentum  patellae — Snapping  knee — Congenital  contraction  at  the 
knee — General  contractions — Acquired  genu  recurvatum 324 

CHAPTER   XI. 

DISEASES    AND    INJURIES    OF    THE    ANKLE    JOINT. 

Tuberculous  disease — Pathology — Etiology — Statistics — Symptoms — Di- 
agnosis— Treatment — Prognosis — Tuberculous  disease  of  the  tarsus 
— Statistics — Treatment — Sprain  of  the  ankle — Teno-synovitis — 
Other  affections  of  the  ankle  joint 334 

CHAPTER   XII. 

DISEASES    AND    INJURIES    OF    THE    ARTICULATIONS    OF    THE 
UPPER    EXTREMITY. 

Tuberculous  disease  of  the  shoulder  joint  —  Pathology  —  Statistics — 
Symptoms — Treatment — Prognosis — Tuberculous  disease  of  the  el- 
bow joint — Pathology — Statistics — Symptoms — Treatment — Prog- 
nosis— Tuberculous  disease  of  the  wrist  joint — Symptoms — Treat- 
ment— Prognosis — Spina  ventosa — Periarthritis  of  the  shoulder 
joint — Chronic  bursitis  at  the  shoulder — Sprain  of  the  wrist — 
Acute  teno-synovitis  at  the  Avrist 348 

CHAPTER   XIII. 

CONGENITAL    AND    ACQUIRED    AFFECTIONS    LEADING    TO 
GENERAL    DISTORTIONS. 

Rhachitis — Etiology — Pathology — Symptoms,  deformities — Prognosis — 
Treatment — "Late  rickets" — "Foetal rhachitis" — Infantile  scorbu- 
tus—^Fragilitas  ossium — Osteomalacia — Osteitis  deformans — Secon- 
dary hypertrophic  osteo-arthropathy — Acromegalia 361 

CHAPTER   XIV. 

CONGENITAL    DISLOCATION    OF    THE    HIP    AND    COXA    VARA. 

Congenital  dislocation  of  the  hip  joint— Statistics — Pathology — Etiology 
— Symptoms — Diagnosis — Differential    diagnosis — Treatment  —  the 


X  CONTENTS. 

open  operation — the  Lorenz  operation — the  intermediate  operation — 
secondary  osteotomy — Palliative  treatment — Coxa  vara — Pathology 
— Etiology — Statistics  —  Symptoms — Diagnosis — Treatment — me- 
chanical—operative. Fracture  of  the  neck  of  the  femur — Trau- 
matic separation  of  the  epiphysis  of  the  head  of  the  femur 373 

CHAPTER   XV. 

DEFOEMITIES    OF    THE    BONES    OF    THE    LOWER    EXTREMITY. 

Bow  leg — Knock  knee — Statistics — Etiology — The  outgrowth  of  defor- 
mity— Genu  valgum — Description — Attitudes — Secondary  defor- 
mities —  Gait  —  Unilateral  deformity  —  Pathology  —  Treatment — 
expectant  —  mechanical  —  operative  —  Genu  varum,  Varieties — 
Symptoms — Treatment — Expectant — mechanical  —  operative — An- 
terior bow  leg — General  rhachitic  distortions 405 

CHAPTER    XVI. 

DEFORMITIES    OF    THE    UPPER    EXTREMITY. 

Congenital  dislocation  of  the  shoulder — Obstetrical  paralysis — Recur 
rent  dislocation  of  the  shoulder — Congenital  deformities  of  the 
elbow — Cubitus  valgus — Cubitus  varus — Subluxation  of  the  wrist — 
Club  hand — Varieties — Club  hand  associated  with  defective  devel- 
opment— Congenital  contraction  of  the  fingers — Webbed  fingers — 
Trigger  finger — Mallet  finger — Baseball  finger — Dupuytren's  con- 
traction    430 

CHAPTER   XVII. 

DISEASES    OF    THE    NERVOUS    SYSTEM. 

Acute  anterior  poliomyelitis — Pathology — Etiology — Statistics — Symp- 
toms— Causes  of  deformity — Deformity  in  various  regions — Sublux- 
ation— Retardation  of  growth^Treatment,  mechanical,  operative...  440 

CHAPTER   XVIII. 

DISEASES   OF   THE    NERVOUS    SYSTEM,    CONTINUED. 

Cerebral  paralysis  of  childhood — Description — Distribution — Etiology — 
Pathology — Symptoms — Congenital  paralysis — Acquired  paralysis 
— Treatment — Prognosis — Progressive  muscular  atrophy — Varieties 
— Symptoms — Hereditary  ataxia — Neuritis — Functional  affections 
of  the  joints — "  Hysterical  "  hip — Differential  diagnosis — "  Hyster- 
ical ' '  club  foot — ' '  Hysterical ' '  scoliosis — Neurotic  joints 459 

CHAPTER  XIX. 

CONGENITAL    AND    ACQUIRED    TORTICOLLIS. 

Description — Statistics— Congenital  torticollis — Etiology — Hsematoma  of 
the  sterno-mastoid  muscle—Acquired  torticollis — Varieties — Acute 


CONTENTS.  XI 

torticollis — Etiology — Symptoms — Diagnosis — Treatment  of  torti- 
collis— chronic,  acute — Spasmodic  torticollis — Etiology — Pathology 
— Treatment — Exceptional  forms  of  torticollis — paralytic — diphthe- 
ritic— cervical  opisthotonos,  rhachitic — ocular — psychical 474 


CHAPTER  XX. 

DISABILITIES    AND    DEFORMITIES    OF    THE    FOOT. 

General  description  of  the  foot  and  of  its  functions,  the  arches,  the  foot 
as  a  passive  support,  in  activity — Improper  postures — Movements 
— Function  of  the  muscles — Strength  of  the  muscles — The  foot  as  a 
mechanism — The  weak  foot  or  so-called  flat  foot — Description — 
Anatomy — Pathology — Etiology — Statistics — Symptoms — Diagnosis 
— Varieties — Weak  foot  in  childhood — Treatment,  preventive — 
Exercises — Support — Construction  of  brace — The  rigid  weak  foot — 
Forcible  correction  of  deformity — Subsequent  treatment — Adjuncts 
in  treatment — Operative  treatment .  492 

CHAPTER  XXI. 

DISABILITIES    AND    DEFORMITIES    OF    THE    FOOT,    CONTINUED. 

The  hollow  foot — Anterior  metatarsalgia — Achillo  bursitis — Achillo- 
bursitis  posterior — Strain  of  the  tendo  Achillis — Calcaneo-bursitis 
— Plantar  neuralgia — Erythromelalgia — Hallux  rigidus — Hallux 
varus — Pigeon  toe — Hallux  valgus — Hammer  toe — Overlapping 
toes — Exostoses — Displacement  of  the  peronei  tendons — Shoes, 
effects  of  improper  shoes — Demonstration  of  the  proper  shoe 530 


CHAPTER   XXII. 

DEFORMITIES    OF    THE    FOOT. 

Talipes — Description — Varieties — Statistics  of  talipes,  congenital  and 
acquired — Eelative  frequency  of  the  different  varieties — Congenital 
talipes — Etiology — Anatomy — Symptoms — Principles  of  treatment 
of  infantile  club  foot — Treatment — mechanical — by  plaster  band- 
age— by  braces — restoration  of  function — supervision — Treatment 
ia  older  subjects — forcible  manual  correction — tenotomy — Wolff's 
treatment,  reduction  of  deformity  by  wrenches — Phelps'  operation 
— Operations  on  the  bones — Mechanical  treatment — Other  varieties 
of  congenital  talipes — varus — equinus — calcaneus — valgus — equino- 
valgus —  calcaneo-valgus  —  calcaneo-varus —  equino-cavus — valgo- 
cavus — cavus — Congenital  talipes  associated  with  defective  develop- 
ment— with  absence  of  fibula— with  absence  of  tibia — with  defective 
formation  of  the  foot — Constricting  bands — Congenital  amputation 
— Congenital  oedema — Spina  bifida  and  talipes 560 


xii  CONTENTS. 

CHAPTER  XXIII. 

DEFORMITIES    OF     THE    FOOT,    CONTIXUED. 

Acquired  talipes — Etiology — Diagnosis — Talipes  equinus — Description — 
Etiology — Symptoms — Treatment — mechanical— operative — Talipes 
calcaneus — Description,  development  of  deformity — Symptoms — 
Treatment — mechanical,  operative — Willett's  operation — astraga 
lectomy — Talipes  equino-varus  and  talipes  equino  valgus — Other 
varieties  of  acquired  talipes — Tendon  transplantation  in  the  treat- 
ment of  paralytic  talipes — Tendon  splicing — Arthrodesis 609 


Orthopedic  Surgery. 


CHAPTER    I. 

TUBERCULOUS   DISEASE   OF   THE   SPINE. 

Synonym.  — Pott's  Disease. 

Pott's  disease  is  a  chronic  destructive  ostitis  of  the  bodies  of  the  ver- 
tebrae which  form  the  anterior  or  weight-supporting  portion  of  the  spinal 
column.  As  the  disease  progresses  the  spine  bends  at  the  weakened 
point,  and  the  upper  part,  sinking  downward  and  forward,  throws  into 
relief  the  spinous  processes  at  the  seat  of  disease ;  thus  an  angular 
posterior  projection  is  formed.  It  is  called  Pott's  disease  because  sucn 
deformity,  slow  in  formation,  accompanied  by  pain  and  sometimes  by 
paralysis,  was  first  described  accurately  by  Percival  Pott,  in  1779. 
Angular  deformity  is,  ho^vever,  simply  the  evidence  of  destruction  of 
a  portion  of  the  anterior  part  of  the  vertebral  column.  Thus  it  might 
be  the  result  of  fracture,  or  of  the  erosion  of  an  aneurism,  or  of  malig- 
nant disease,  or  syphilis  or  other  pathological  process ;  but  deformity 
from  such  causes  is  not  now  included  under  Pott's  disease,  nor  is  the 
term  now  synonymous  with  deformity.  In  the  modern  sense  it  signi- 
fies tuberculous  disease  of  the  bodies  of  the  vertebrae,  of  which  the 
early  symptoms  may  be  detected  and  of  which  the  deforming  effects 
may  be  checked  and  even  prevented  by  proper  treatment.  The  com- 
pression and  collapse  of  the  affected  parts  cause  the  characteristic 
angular  projection  at  the  seat  of  disease.  If  one  vertebral  body  is 
destroyed  the  projection  will  be  sharp ;  if  several  are  implicated  it 
will  be  less  angular,  and  if  one  side  of  a  body  breaks  down  before  the 
other  there  may  be  a  lateral  as  well  as  a  posterior  distortion. 

The  size  of  the  deformity  and  its  effect  upon  the  individual  depend 
in  great  degree  upon  its  situation.  If  the  disease  is  at  either  e;s:tremity 
of  the  spine  the  angular  projection  must  be  small  because  so  little  of 
the  column  remains  beyond  the  destructive  process  ;  or  in  other  words, 
the  area  of  the  spine  directly  involved  in  the  deformity  is  small  com- 
pared to  that  which  is  free  from  disease.  Thus  the  characteristic  de- 
formity in  the  upper  cervical  region  shortens  the  neck  and  disturbs 
the  poise  of  the  head ;  in  the  lower  lumbar  region  it  shortens  the 
trunk  and  induces  a  peculiar  attitude  and  gait.  In  either  case  the 
actual  local  deformity  is  usually  insignificant  and  the  distortion  of  the 
body  is  comparatively  slight.  But  when  the  middle  of  the  spine  is 
involved,  the  opportunity  for  deformity  is  great  becatise  the  entire 
2 


18 


TUBERCULOUS  DISEASE  OF  THE  SPINE. 


Fig.  1. 


column  may  enter  into  the  formation  of  the  angular  kyphosis ;  thus 
the  internal  organs  are  compressed  and  the  effect  upon  the  vital  mech- 
anism is  disastrous. 

Pott's  disease,  as  contrasted  with  tuberculosis  of  other  bones  and 
joints,  is  peculiar  in  that  it  is  concealed  from  view,  in  that  direct  sur- 
gical intervention  is  of  comparatively  little  avail,  in  that  it  lies  in 
close  proximity  to  important  parts,  the  spinal  cord  behind  and  the 
vital  organs  in  front,  and  finally,  in  that  the  effects  of  the  disease  and 
deformity  are  not  limited  to  the  parts  directly  involved,  but  influence, 
to  a  greater  or  less  degree,  the  entire  mechanism 
of  the  body. 

Pathology. — The  minute  changes  that  char- 
acterize tuberculosis  of  bone  in  general  are  de- 
scribed in  Chapter  V. 

The  first  indication  of  the  disease  is  usually 
found  in  the  anterior  part  of  a  vertebral  body 
just  beneath  the  fibro-periosteal  layer  of  the  an- 
terior longitudinal  ligament.  From  this  point 
the  granulation  tissue  advances  along  the  front  of 
the  spine  and,  following  the  course  of  the  blood 
vessels,  it  invades  and  destroys  the  adjacent  ver- 
tebral bodies.  In  other  instances  the  disease 
may  begin  in  the  interior  of  a  vertebral  body, 
most  often  in  several  minute  foci  near  the  upper 
or  lower  epiphysis.  These  coalescing,  gradually 
enlarge,  forming  a  cavity,  surrounded  for  a  time 
by  unbroken  cortical  substance,  which  becoming 
weaker  collapses  under  the  pressure  of  the  super- 
incumbent weight.  Occasionally  the  disease  ad- 
vances beneath  the  anterior  ligament  without 
implicating  deeply  the  substance  of  the  bone,  a 
form  of  tuberculous  periostitis,  "  spondylitis 
superficialis." 

The  inter-vertebral  discs  appear  to  offer  some 
resistance  to  the  extension  of  the  disease  from 
one  vertebra  to  another,  but  when  the  bone  is  de- 
stroyed on  either  side  they  quickly  disintegrate 
and  disappear.  The  posterior  part  of  the  spinal 
column  usually  remains  practically  free  from  disease  with  the  excep- 
tion of  the  pedicles  and  articulations  which  may  be  in  direct  contact 
with  the  tuberculous  process.  In  rare  instances  the  disease  may  begin 
in  a  lamina  or  spinous  process,  or  one  of  the  small  joints  may  be 
primarily  involved,  but  such  forms  of  local  tuberculosis  would  hardly 
be  classed  as  Pott's  disease  unless  the  anterior  part  of  the  spine  were 
implicated  also. 

The  course  and  outcome  of  the  disease  depends  upon  its  type.  In 
one  instance  the  area  of  primary  infection  is  small  and  the  local  re- 
sistance is  sufficient  to  check  its  further  progress,  so  that  cure  without 


Destruction  of  the  bodies 
of  the  first,  second  and  third 
lumbar  vertebrse — with  the 
resulting  deformity.     (M:6- 

NARD.) 


PATHOLOGY. 


19 


deformity  may  follow  ;  or  it  may  advance  slowly,  accompanied  by  a 
process  ,6f  repair  ;  the  area  of  active  disease  is  small  and  the  granula- 
tion tissue  undergoes  a  fibroid  transformation  or  becomes  ossified.  In 
such  cases  deformity  may  appear  and  slowly  increase,  practically  with- 
out symptoms.  In  most  instances  however,  the  tuberculous  granula- 
tions advance  more  rapidly,  destroying  the  bone  or  other  tissue  with 

Fig.  2. 


Pott's  disease. 


which  they  come  in  contact ;  the  usual  retrograde  metamorphosis  to 
cheesy  degeneration  follows  and  very  frequently  liquefaction  or  abscess 
formation  ;  the  latter  change  being  caused  possibly  by  secondary  in- 
fection with  pyogenic  germs.  Clinically  the  liability  to  abscess  is 
very  much  increased  by  irritation  or  injury  and  is  decreased  by  abso- 
lute rest  of  the  diseased  part. 


20  TUBERCULOUS  DISEASE   OF  THE  SPINE. 

As  a  rule,  in  those  cases  of  moderate  severity,  that  come  to  autopsy 
during  the  progressive  stage  of  the  disease,  one  finds  on  dividing  the 
thickened  tissues  in  front  of  the  spine,  a  cavity,  the  walls  of  which  are 
lined  with  tuberculous  granulations  in  various  stages  of  degeneration, 
and  containing  puriform  fluid.  The  adjoining  vertebral  bodies  pre- 
sent a  worm-eaten  appearance  and  one  or  more  of  them  is  partially 
destroyed.  Small  fragments  of  necrosed  bone  and  "bone  sand"  may 
be  present,  together  with  larger  masses  of  degenerated  tissue ;  in  rare 
instances  sequestra  of  considerable  size  may  be  found. 

Occasionally  the  disease  may  begin  in  the  posterior  part  of  a  verte- 
bral body,  or  it  may  extend  backward  as  well  as  forward,  and,  forcing 
its  way  into  the  vertebral  canal,  it  may  press  upon  the  spinal  cord  and 
involve  its  coverings,  and  thus  cause  paralysis  of  the  parts  below. 
Less  often  pressure  on  the  cord  may  be  due  to  the  presence  of  an 
abscess  or  to  a  projecting  fragment  of  bone. 

The  calibre  of  the  spinal  canal  may  be  constricted  somewhat  by  the 
pressure  of  the  superincumbent  weight  upon  the  softened  and  thick- 
ened tissues  at  the  seat  of  disease,  but  as  a  rule,  its  capacity  is  not 
directly  lessened  by  the  angular  distortion  nor  does  the  degree  of  de- 
formity directly  influence  the  frequency  of  paralysis. 

Although  the  disease  may  begin  in  multiple  primary  foci  of  infection 
over  an  extended  area,  or  in  two  or  more  distinct  regions  of  the  spine 
simultaneously,  yet  clinical  observation  seems  to  show  that  it  is,  in 
most  instances,  originally  confined  to  one  or  two  adjacent  bodies,  one  or 
both  of  which  are  partially  destroyed ;  from  this  central  point  the  dis- 
ease may  extend  in  either  direction  until  half  the  spine  may  be  impli- 
cated, but  in  ordinary  cases  the  final  area  of  deformity  and  rigidity 
shows  that  from  three  to  six  bodies  are  more  or  less  involved  before 
cure  is  established. 

If  the  disease  is  limited  in  extent,  the  eroded  surfaces  of  the  adjoin- 
ing vertebree  may  come  into  direct  contact,  but  if  several  vertebral 
bodies  have  been  destroyed  the  upper  portion  of  the  spine  as  it  sinks 
downward  is  often  displaced  backward  so  that  the  anterior  aspect  of 
one  or  more  of  the  upper  segments  may  be  apposed  to  the  superior 
surface  of  the  first  body  of  the  lower  section  (Fig.  3).  Less  often  there 
may  be  forward  displacement  of  the  upper  part  upon  the  lower  (Fig.  1). 

At  all  stages  of  the  disease  resistance  to  its  progress,  and  efforts  at 
repair  are  evident  in  the  affected  parts.  When  this  resistance  over- 
balances the  tendency  to  degeneration,  cure  follows. 

Repair  is  accomplished  occasionally  by  contact  and  solid  union  of 
the  adjoining  surfaces  of  softened  bone,  but  usually  the  anchylosis  is 
in  part  fibrous,  in  part  cartilaginous  and  in  part  bony,  and  this  union 
may  be  further  strengthened  by  a  callous  formation  from  the  thickened 
tissues  about  the  seat  of  disease. 

In  many  instances  the  articular  processes,  the  pedicles  and  laminae 
become  anchylosed  before  repair  has  advanced  appreciably  in  the  an- 
terior portion  of  the  column. 

Cure  may  be  absolute,  as  when  no  vestige  of  the  disease  remains ; 


ETIOLOGY. 


21 


it  may  be  practically  complete,  as  when  the  diseased  products  undergo 
calcareotis  degeneration  and  are  shut  in  by  a  layer  of  solid  bone.  In 
other  instances  the  disease  becomes  quiescent  or  but  slowly  advances, 
showing  its  presence  by  exacerbations  of  pain  or  by  the  formation  of 
an  abscess,  long  after  active  symptoms  have  ceased. 

Etiology. — The  etiology  of  tuberculosis  of  the  spine  does  not  differ 

Fig.  4. 


DestFuction  of  the  bodies  of  the  third, 
fourth,  fifth,  sixth  and  seventh  dorsal  verte- 
brae ;  partial  destruction  of  three  others. 
(M:6nard.) 


The  deformity  corrected  showing  the  area 
of  the  destructive  process.    (Menaed.) 


from  that  of  tuberculosis  of  other  bones  ;  the  subject  is  considered 
in  Chapter  V. 

Relative  Frequency. — Tuberculosis  of  the  spinal  column  is  more 
common  than  of  any  other  single  bone  or  joint,  as  might  be  ex- 
pected from  its  greater  area.  This  point  is  illustrated  by  the  sta- 
tistics of  tuberculous  disease  treated  in  the  out-patient  department  of 


22  TUBERCULOUS  DISEASE   OF  THE  SPINE. 

the  Hospital  for  Ruptured  and  Crippled,  jSTew  York,  during  a  period 
of  fifteen  years,  1885-1899. 

Tuberculosis  of  the  Spine 3,207  cases. 

"  "     "    Hip     2,230     " 

"  "   other  joints  inclusive 2,408     " 

Also  by  similar  statistics  contained  in  a  recent  report  of  the  Boston 
Children's  Hospital,  for  a  longer  period,  1869-1893. 

Tuberculosis  of  the  Spine 1,864  cases. 

"             "    "     Hip,   Knee,  Ankle, 
Shoulder,  Elbow  and  Wrist  combined 1,856     " 

Age. — Pott's  disease,  although  far  more  frequent  in  the  middle 
period  of  childhood,  from  the  third  to  the  tenth  years,  may  occur  at 
any  time  from  earliest  infancy  to  extreme  old  age. 

In  a  series  of  1,259  consecutive  cases  of  tuberculosis  of  the  spine 
collected  from  the  records  of  the  outdoor  department  of  the  Hospital 
for  Ruptured  and  Crippled,  'New  York,  analyzed  for  me  by  Drs.  R. 
T.  Frank  and  C.  Gunter,  the  ages  of  the  patients  at  the  supposed  time 
of  onset  of  the  disease  appeared  to  be  as  follows  : 

Less  than  1  year 38... 

Between    1  and    2  years 176... 

"  3     "       5      "       627... 

"  6    "     10      "       234.., 

"         11    "     20      "       89.., 

"         21    "     30      "        43... 

"         31    "     50      "       31... 

Over     50      "       11.. 


3.1  p( 

er  cent. 

14.2 

50.2 

18.3 

,  7.2 

3.5 

2.6 

The  youngest  patient  was  two  months  old,  the  oldest  seventy-one  years. 

Dr.  Thorndike,^  of  Boston,  from  the  records  of  the  Boston  Children's 
Hospital  for  thirteen  years,  1883  to  1896,  collected  115  cases  of  tuber- 
culosis of  the  spine  in  children  of  two  years  or  less.  Seven  of  these 
were  less  than  six  months,  and  twenty  were  under  one  year  in  age. 

Mr.  Howard  Marsh "  has  called  attention  to  Pott's  disease  of  the 
aged,  and  cites  three  cases  in  subjects  of  sixty  or  more  years  of  age. 

Sex. — Sex  exercises  comparatively  little  influence  on  the  liability  to 
disease  of  this  region.  Of  3,797  cases  collected  by  Mohr,  Gibney, 
Fischer,  Taylor  and  Bradford  and  Lovett,  quoted  by  HofPa,  2,045 
were  in  males  and  1,752  were  in  females.  Of  1,367  cases  collected 
by  Frank  and  Gunter,  708  (52  per  cent.)  were  in  males  and  659  (48 
per  cent.)  were  in  females  ;  and  in  2,455  cases  tabulated  by  Knight 
1,329  were  in  males  and  1,126  in  females.  In  these  combined  cases 
from  the  Hospital  for  Ruptured  and  Crippled  3,822  in  number,  53.2 
per  cent,  were  in  males  and  46.8  per  cent,  in  females. 

The  Situation  of  the  Disease. — The  dorso-lumbar  section  of  the 
spine  is  most  often  affected.    Cervical  ostitis  is  comparatively  infrequent. 

In  the  series  of  1,355  cases  from  the  records  of  the  Hospital  for 

1  Trans.  Am.  Ortho.  Ass'n,  Vol.  IX.,  1896. 

2  Ibid.,  Vol.  IV.,  1891. 


THE  SITUATION  OF  THE  DISEASE.  23 

Ruptured  and  Crippled,  the  attempt  was  made  to  locate  the  origin  of 
the  disease  by  the  most  prominent  spinous  process  in  the  tracing. 
The  following  are  the  conclusions. 

Cervical.  Dorsal.  Lumbar.  Lumbo-sacral. 

1st 3  1st 26    1st 94         13 

2d 3  2d 43    2d 96 

3d 15  3d 42         3d 64         No  Deformity. 

4th 20  4th 46         4th 57         Cervical  2 

5th 13  5th 49         5th 6         Dorsal.  31 

6th 22  6th 76  327       Lumbar !22 

7th 24  7th 82  -55 

loo  8th 97 

9th 92  Disease  in  two  regions  of  the  spine. 

10th 110  16 

11th 71 

12th 120 

854 

Similar  statistics  are  recorded  by  Julius  DoUinger/  of  Budapesth,  of 
700  cases  of  Pott's  disease.  Of  these  the  situation  of  the  primary  dis- 
ease could  be  ascertained  in  538.  Of  this  number,  in  63  the  disease  was 
of  the  cervical,  in  321  of  the  dorsal  and  in  154  of  the  lumbar  region. 

The  relative  frequency  of  disease  of  the  different  dorsal  and  lumbar 
vertebrae,  was  as  follows  : 

Dorsal.  Lumbar. 

1st 6  1st 59 

2d.  7  2d 37 

3d 12  3d 31 

4th 10  4th 17 

5th 19  5th 10 

6th 17  154 

7th 33 

8th 36 

9th 36 

10th 43 

11th 38 

12th 64 

3"21 

The  proportionate  length  of  the  different  sections  of  the  spine  at  the 
age  of  five  years  is,  according  to  Professor  Disse  (Skeletlehre,  1896)  : 

Cervical 20.2 

Dorsal 45.6 

Lumbar 34.2 


100.0 


If  this  be  contrasted  with  the  percentage  of  the  cases  of  disease  of 
each  section,  it  will  show  that  the  frequency  of  the  disease  in  the  dif- 
erent  regions  of  the  spine  does  not  correspond  to  the  area,  as  has  been 
suggested,  but  that  it  is  proportionately  much  less  frequent  in  the  cer- 
vical and  much  more  frequent  in  the  dorsal  region ;  a  frequency  that 
may  be  explained  by  the  greater  strain  to  which  the  middle  and  lower 
>  Die  Behandlung  der  Tuberculosen  Wirbelentziindung.     Stuttgart,  1-896. 


24  TUBERCULOUS  DISEASE  OF  THE  SPINE. 

part  of  the  spine  is  subjected,  as  well  as  by  the  relative  proportion  of 
cancellous  tissue  which  offers  the  opportunity  for  infection! 

Bollinger.  Frank  and  Gunter. 

Cervical 11.7  per  cent.  Cervical 7.6  per  cent. 

Dorsal 59.6    "■       "  Dorsal 66.1    "       " 

Lumbar 28.6     ''       "  Lumbar 26.2    "       " 

Prognosis. — The  prognosis  in  tuberculous  disease  is  discussed  in 
Chapter  V.  :  Pott's  disease  is  the  most  dangerous  of  all  the  tuberculous 
affections  of  the  bones  or  joints,  as  would  be  expected  from  the  rela- 
tive importance  of  the  structure  affected  and  of  the  parts  lying  in 
contact  with  it. 

It  is  evident  also  that  the  amount  of  deformity,  and  its  situation, 
have  a  direct  influence  on  the  prognosis. 

In  the  typical  "  hump-back  "  deformity,  the  contents  of  the  thorax 
and  abdomen  are  necessarily  compressed,  the  blood-vessels  are  dis- 
torted and  the  calibre  of  the  aorta  is  thereby  often  much  diminished. 
Respiration  is  made  difficult,  and  the  circulation  is  impeded,  so  that  the 
heart  is  usually  hypertrophied  and  valvular  insufficiency  is  not  infre- 
quent ;  thus  the  vital  functions,  which  are  carried  on  at  a  disadvan- 
tage even  under  favorable  conditions,  become  impossible  under  the 
added  strain  of  unfavorable  surroundings,  overwork  or  disease.  It 
is  a  matter  of  common  observation  also  that  few  of  those  who  are 
markedly  deformed  reach  old  age.  On  the  other  hand,  it  may  be  as- 
sumed that  slight  deformities,  or  those  which  do  not  as  directly  inter- 
fere with  the  vital  functions,  exercise  but  little  influence  upon  the 
future  well-being  of  the  patient. 

Although  the  absolute  mortality  of  Pott's  disease  cannot  be  accu- 
rately estimated,  it  may  be  stated  that  at  least  20  per  cent,  of  all 
patients  die  during  the  progress  of  the  disease  and  within  a  few  years 
after  its  onset,  from  causes  directly  or  indirectly  dependent  upon  the 
local  lesion.  Some  of  these  die  from  general  dissemination  of  the 
tuberculous  infection  and  tuberculous  meningitis  ;  some  from  exhaus- 
tion following  septic  infection  and  long-continued  suppuration,  or  from 
amyloid  degeneration  of  the  internal  organs  ;  some,  from  tuberculosis 
of  the  lungs,  and  many,  from  intercurrent  affections  that  are  fatal  be- 
cause of  the  devitalizing  influence  of  the  disease  and  its  complications. 

The  prognosis  of  Pott's  disease,  in  the  individual  case,  is  influenced 
by  many  considerations.  In  one  instance  the  family  history  is  good, 
the  surroundings  are  favorable,  the  patient  is  in  good  condition  and  the 
disease  is  in  the  early  stage ;  one  is  then  inclined  to  look  upon  it  as 
ian  accident,  and  hardly  considers  the  possibility  of  a  fatal  termination. 
While  in  another  case,  the  weakness  and  under-vitalization  of  the 
body  are  so  evident,  that  the  affection  of  the  spine  seems  but  an  in- 
cident of  a  general  degeneration. 

Symptoms. — The  most  distinctive  sign  of  Pott's  disease  is  deform- 
ity. At  an  early  stage  of  the  process  there  may  be  but  a  slight  irreg- 
ularity in  the  contour  of  the  spine,  and  if  several  adjacent  vertebral 


SYMPTOMS.  25 

bodies  are  aifected  the  projection  may  be  somewhat  rounded  in  out- 
line. B&t,  as  compared  with  other  deformities  of  the  spine,  that  of 
Pott's  disease  is  characteristically  angular,  and  as  its  cause  is  loss  of 
substance,  its  formation  is  accompanied  by  and  must  have  been  pre- 
ceded by  the  symptoms  of  bone  disease. 

Deformity  is  thus  the  evidence  of  a  destructive  process  that  may 
have  existed  for  weeks  or  months  even,  and  only  by  its  early  recogni- 
tion can  the  ideal  result,  the  prevention  of  deformity,  be  attained. 
For  the  spine  which,  although  weak,  is  still  straight  may  be  kept 
straight,  but  when  the  deformity  is  present,  it  can  be  remedied  only  in 
part,  and  it  may  be  difficult  even  to  check  its  further  progress.  For 
as  the  upper  segment  of  the  spine  sinks  forward  and  downward,  the 
influences  of  compression  and  attrition  increase  the  activity  of  the  local 
process  and  aggravate  its  eifects. 

Angular  deformity  has  been  long  considered  as  the  essential  sign  of 
Pott's  disease,  and  even  now,  the  fact  is  not  generally  recognized  that 
the  detection  of  tuberculous  ostitis  of  the  spine  in  the  early  stage,  is 
both  possible  and  easy  by  the  same  methods  that  serve  for  the  diag- 
nosis of  other  affisctions,  not  attended  by  such  obvious  symptoms  as 
external  deformity.  It  is  to  such  application  of  the  principles  of  dif- 
ferential diagnosis  that  attention  is  especially  called. 

As  the  spine  is  the  chief  support  of  the  body  and  as  it  allows  a  free 
mobility  that  accommodates  it  to  every  movement  of  the  trunk  and  to 
every  motion  of  the  limbs  even,  it  is  evident  that  the  symptoms  of  a 
destructive  ostitis  must  be  pain,  weakness,  and  impairment  of  normal 
motion.  Motion  and  support  are  not,  however,  the  only  functions  of 
the  spine  ;  it  contains  the  spinal  cord,  from  which  branch  the  nerves 
that  supply  the  organs  and  members  of  the  body.  This  may  be  im- 
plicated even  at  an  early  stage  of  the  aifection,  and  the  sudden  onset 
of  paralysis  may  overshadow  the  symptoms  of  original  disease.  Or 
the  tumor  of  an  abscess,  one  of  the  common  accompaniments  of  tuber- 
culous disease  of  bone,  may  interfere  with  the  functions  of  important 
parts  lying  in  the  neighborhood  of  the  spine,  thus  peculiar  symptoms, 
due  to  this  cause,  may  attract  attention  before  the  primary  disease  is 
■  suspected.  These  are  symptoms  that  may  be  misleading  and  it  is  well, 
therefore,  to  consider  them  apart  from  those  that  indicate  the  primary 
effect  of  the  disease  upon  the  spine,  considered  as  an  elastic  support. 
These  direct  symptoms  usually  precede,  and  always  accompany  the  sec- 
ondary or  complicating  symptoms,  and  upon  them  the  diagnosis  depends. 

The    primary    and  diagnostic  symptoms  of  Pott's  disease 

MAY    BE    classified    AS    FOLLOWS  : 

(a)  Pain. 
{h)  Stiffness. 
(c)  Weakness. 
(c?)  Awkwardness. 
(e)  Deformity. 

{a)  Pain. — At  first  thought,  one  might  expect  the  pain  of  Pott's 
disease  to  be  localized  at  the  affected  vertebrae,  and  to  be  accompanied 


26 


TUBERCULOUS  DISEASE  OF  THE  SPINE. 


Fig.  5. 


by  sensitiveness  to  pressure  or  even  by  infiltration  and  swelling  of  the 
tissues,  but  it  will  be  remembered  that  the  bodies  of  the  vertebrae  are 
in  the  interior  of  the  trunk,  practically  speaking,  as  near  to  its  anterior 
as  to  its  posterior  surface  (Fig.  9)  and  that  the 
products  of  the  disease  pass  downward  and 
forward,  rarely  backward. 

Thus  sensitiveness  to  pressure  on  the  project- 
ing spinous  processes  is  unusual,  and  palpation, 
except  in  the  cervical  region,  is  of  compara- 
tively little  diagnostic  value. 

The  pain  of  Pott's  disease  is  not  localized 
in  the  back,  in  the  neighborhood  of  the  dis- 
ease, because  the  nerve  filaments  that  supply 
the  bodies  of  the  vertebrae  are  insignificant 
parts  of  nerves  that  are  distributed  to  distant 
points,  to  the  head,  to  the  legs,  to  the  front  and 
sides  of  the  body  and  to  these  parts  the  pain 
is  referred;  thus  "earache"  or  "stomach-ache" 
or  "  sciatica  "  may  be  symptomatic  of  Pott's 
disease  of  the  different  regions  of  the  spine. 

The  pain  of  Pott's  disease  is  by  no  means 
constant,  it  is  induced  by  jars  or  by  sudden  or 
unguarded  movements.  It  is  often  worse  at 
night,  when  after  the  relaxation  of  the  muscu- 
lar spasm  that  has  protected  the  part,  the  un- 
conscious movements  during  sleep  cause  dis- 
comfort or  pain  and  the  child  moans  in  its 
sleep,  or  is  restless,  and  sometimes  it  wakes 
with  a  cry — "  night  cry." 
■^^^  (b)  Impairment  of  Function  or  Loss  of  Normal 
Mobility — Stiffness. — Stiffness  of  the  spine,  the  result  of  the  destructive 
ostitis,  is  in  part  voluntary,  in  the  sense  that  the  patient  adapts  his 
movements  and  attitudes  to  the  disease  and  pain  and  thus  avoids,  if 
possible,  strain  and  jar — but  the  essential  and  characteristic  stiffness 
of  Pott's  disease  is  caused  by  the  involuntary  muscular  tension  and 
contraction  of  the  muscles  about  the  seat  of  disease.  This  reflex  mus- 
cular spasm  varies  in  degree,  according  to  the  state  of  the  underlying 
disease.  It  may  fix  the  spine  or  it  may  be  evident  only  at  the  extremes 
of  motion,  but  it  is  always  present,  preceding  deformity  and  accom- 
panying it  until  cure  is  established  ;  thus  it  is  the  most  important  of 
the  diagnostic  symptoms  of  Pott's  disease. 

(c)  Weakness. — As  the  disease  affects  the  most  important  support 
of  the  body,  it  is  a  direct  as  well  as  an  indirect  cause  of  weakness, 
and  the  more  vulnerable  the  spine,  the  more  pronounced  is  this  symp- 
tom ;  thus  in  the  young  child,  whose  spine  is  in  great  part  cartilaginous, 
evidence  of  weakness  is  shown  by  the  "loss  of  walk,"  the  refusal  to  stand 
or  the  instinctive  desire  for  support,  at  an  early  stage  of  the  disease. 

(d)  Change  in  Attitude — "  Awkwardness." — This  really  suras  up  the 


direct  deformity; 
pensatory  deformity. 


V'^ 


SYMPTOMS. 


27 


effects  of  the  preceding  symptoms,  since  it  is  evident  that  pain,  weak- 
ness, and  rigidity  must  cause  a  change  in  the  appearance  and  in  the 
habitual  attitudes  of  the  patient.  Such  symptomatic  attitudes  may  be 
ahuost  diagnostic  of  the  disease  and  of  the  part  of  the  spine  involved. 
(e)  Change  in  the  Contour  of  the  Spine — Deformity. — The  deformities 
of  Pott's  disease  may  be  classified  as  follows  : 

1.  Bone  deformity. 

2.  Muscular  deformity. 

-     3.  Compensatory  deformity. 

The  characteristic  angular  projection  due  to  destruction  of  bone  has 
been  described  already. 

Muscular  deformity  is  the  distortion  due  to  muscular  spasm  or  con- 
traction.    Of  this,  the  wry  neck,  symptomatic  of  cervical  disease,  and 


Fig.  6. 


Normal  contour  and  flexibility  of  the  spine. 


psoas  contraction  in  the  lower  region  of  the  spine,  are  the  most  familiar 
■examples. 

Compensatory  deforniity  signifies  the  more  general  effect  of  the  local 
disease  and  local  distortion,  upon  the  spine  as  a  whole.  (Fig.  5.)  Thus 
an  angula;r  projection  must  be  balanced  by  a  compensatory  incurvation, 
and  lateral  distortion  in  one  direction  by  lateral  distortion  in  another. 
These  deformities  are,  of  course,  nearly  related,  and  they  are  usually 
combined,  although  muscular  distortion  may  precede  the  stage  of  bone 
destruction,  while  the  compensatory  changes  are  not  immediately  ap- 
parent. These  general  and  secondary  changes  in  contour  may  catch 
the  eye  before  the  primary  local  deformity  is  detected. 

Lateral  deviation  of  the  spine  is  not  infrequent  ;  it  may  be  direct 
distortion  at  the  seat  of  disease,  caused  by  the  destruction  of  the  side 
of  a  vertebral   body,  but   more   often  it  is  a  secondary  effect  of  such 


28 


TUBERCULOUS  DISEASE  OF  THE  SPINE. 


irregular  erosion  at  one  or  the  other  extremity  of  the  spine,  or  the 
eflPect  of  muscular  contraction,  or  it  may  be  clue  to  simple  weakness. 

Finally,  even  at  a  much  earlier  stage  of  the  disease,  there  is,  almost 
always,  a  slight  change  in  the  outline  of  the  spine  due  to  local  rigidity  ; 
thus  the  spine  no  longer  forms  a  long  regular  curve  when  the  body  is 
bent  forward,  but  as  one  section  remains  more  or  less  rigid  while  the  other 
bends,  the  outline  is  broken  at  or  near  the  seat  of  the  disease.     (Fig.  7.) 

Secondary  or  Complicating  Symptoms. — (a)  Abscess. — This  may, 
by  its  size  or  situation,  cause  peculiar  symptoms.     In  the  retro-pharyn- 

FiG.  7. 


Incipient  Pott's  Disease. 


Showing  the  break  iu  the  contour  of  the  spine,  of  which  the  normal 
flexibility  is  but  slightly  impaired. 


geal  space  it  may  interfere  with  respiration  and  deglutition.  In  the 
thoracic  region  it  might  be  mistaken  for  pleurisy  or  empysema,  and  when 
it  forms  a  tumor  in  the  iliac  fossa,  it  may  interfere  with  locomotion, 

(6)  Paralysis. — This  is  usually  a  late  symptom,  but  if  the  disease 
begins  in  the  center  or  posterior  part  of  a  vertebral  body  it  may  im- 
plicate the  spinal  cord  before  deformity  is  apparent. 

Abscess  and  paralysis  are  symptoms  that  may  be  explained  by  Pott'& 
disease,  but  other  than  by  calling  attention  to  disease  of  the  spine  as  a 
possible  cause  of  the  complication,  they  do  not  aid  one  in  determining 
the  diagnosis  ;  for  this  reason  they  are  classed  as  secondary  symptoms. 


CONTOUR  AND  FLEXIBILITY  OF  THE  NORMAL  SPINE.        29 

b 

General  Symptoms. — By  some  surgeons,  especial  stress  is  laid  upon 
the  diagnbstic  value  of  a  slight  but  constant  elevation  of  the  tempera- 
ture. This  is  usually  present  if  the  disease  is  active  or  when  an  ab- 
scess is  approaching  the  surface,  but  the  positive  value  of  the  symptom 
in  early  or  quiescent  cases,  is  doubtful.  One  may  expect  also  that  a 
patient  suffering  from  tuberculous  disease  of  the  spine  will  present 
some  evidence  of  a  painful  and  depressing  aifection,  or  some  evidence 
of  inherited  or  acquired  weakness,  yet  it  must  be  remembered  that  the 
absence  of  such  general  symptoms  would  not  exclude  Pott's  disease. 

The  Contour  and  Flexibility  of  the  Normal  Spine. 

In  the  enumeration  of  the  early  symptoms  of  Pott's  disease,  two 
have  been  noted  as  of  especial  importance  :  the  impairment  of  normal 
mobility  and  the  effect  of  the  disease  upon  the  contour  of  the  spine 
and  upon  the  attitudes  of  the  patient.  Therefore,  in  the  study  of  the 
normal  spine,  the  standard  with  which  that  suspected  of  disease  must 
be  compared,  mobility  and  contour,  at  different  ages,  and  under  differ- 
ent conditions,  should  receive  especial  consideration. 

Although  the  spine  as  a  whole  is  a  flexible  column,  yet  it  has  a 
fixed  contour ;  it  curves  forward  in  the  upper,  backward  in  the  mid- 
dle, and  forward  again  in  the  lower  region.  These  curves  are,  in  great 
degree,  the  effect  of  the  force  of  gravity  and  of  the  action  of  the 
muscles  in  balancing  the  weight  of  the  body  in  the  upright  attitude. 
In  the  adult  they  are  practically  permanent ;  in  early  childhood  they 
can  be  nearly  obliterated  by  traction  in  the  horizontal  position  ;  and 
in  infancy  they  do  not  exist.  If  the  newborn  infant  be  placed  in  the 
sitting  posture  the  head  falls  forward  and  the  spine  bends  in  one  long 
backward  curve  characteristic  of  weakness.  If  it  be  placed  on  the 
back  and  the  legs  be  drawn  down  from  their  habitual  attitude  of  semi- 
flexion, it  will  be  noticed  that  the  range  of  extension  is  somewhat 
limited  because  of  the  absence  of  the  lumbar  curve  and  inclination  of 
the  pelvis.  When  the  gain  in  muscular  power  has  been  sufficient  to 
enable  the  infant  to  raise  and  control  the  head  the  curve  of.  the  neck 
appears.  Later  when  the  child  stands  the  erector  spinee  muscles  hold 
the  body  upright  against  the  resistance  of  the  ilio  psoas  group  and  of 
the  ligaments  of  the  hip  joint ;  thus  the  lumbar  curve  and  the  incli- 
nation of  the  pelvis  result  and  the  normal  contour  of  the  spine  is 
established. 

If  from  the  odontoid  process  of  the  axis  of  a  normal  individual  in 
the  erect  posture  a  line  be  dropped  to  the  ground,  this  perpendicular 
or  weight  line,  about  which  the  weight  of  the  body  is  balanced,  will 
indicate  the  curves  of  the  spine,  and  divide  it  into  sections  that  corre- 
spond sufficiently  well  to  function.  The  cervical  curve  ends  at  the 
second  dorsal,  the  thoracic  curve  at  the  twelfth  dorsal  and  the  lumbar 
curve  at  the  sacro-vertebral  angle.     (Fig.  8.) 

What  has  been  spoken  of  as  the  normal  contour  of  the  spine  varies 
considerably  in  the  adult.     It  is  affected  by  the  occupation,  and  many 


30 


TUBERCULOUS  DISEASE  OF  THE  SPINE. 


Fig.  8. 


other  circumstances ;  of  this,  the  round  shoulders  of  the  cobbler  or 
the  weaver,  the  stoop  of  weakness,  of  old  age  and  the  like  are  familiar 
examples  :  but  in  childhood,  distinct  variations  from  the  normal  con- 
tour almost  always  have  a  clearly  defined 
pathological  cause.  As  the  normal  contour 
is  the  efPect  of  the  balancing  of  the  body  in 
the  upright  posture,  it  is  evident  that  if  the 
outline  of  one  part  is  permanently  changed, 
compensation  for  this  change  must  be  made 
in  another  part.  Thus  when  deformity  is 
well  marked,  the  normal  curves  of  the  spine 
are  often  completely  reversed  (Fig.  5),  and 
even  at  an  early  stage  of  the  disease,  the 
abnormal  contour  will  often  attract  atten- 
tion, long  before  the  characteristic  angular 
projection  has  become  apparent. 

Although  the  spine  is  a  flexible  column 
that  is  constantly  changing  in  outline  with 
every  movement  and  posture  yet  the  range 
and  character  of  this  motion  vary  greatly  in 
its  different  parts.  In  the  cervical  and  lumbar 
regions  motion  is  extensive,  because  of  the 
relatively  large  proportion  of  elastic  inter- 
vertebral substance,  because  of  the  direction 
of  the  articular  surfaces,  and  because  the 
center  of  motion  is  near  the  middle  of  the 
body.  Motion  is  very  limited  in  the  thoracic 
region,  because  the  intervertebral  discs  are  thin,  because  of  the  over- 
lapping spinous  processes  and  because  it  forms  a  part  of  the  rigid 
thorax.  "Where  free  motion  is  essential  to  the  habitual  attitudes,  there 
disease,  which  interferes  with  normal  motion,  will  be  earliest  apparent, 
in  awkwardness,  weakness,  and  pain,  and  there,  muscular  spasm,  the 
chief  cause  of  the  rigidity  and  restraint  of  normal  motion,  will  be 
evident  on  examination. 

Thus  one  more  often  has  the  opportunity  to  make  an  early  diagnosis 
in  disease  of  the  lumbar  and  cervical  regions,  because  in  the  one  the 
motions  necessary  in  stooping,  sitting  and  standing  are  constrained, 
and  in  the  other  the  neck  is  stiff,  or  the  head  is  turned  or  drawn  from 
the  normal  line.  In  the  thoracic  region,  early  diagnosis  is  less  often 
made,  because  in  this  section  motion  is  so  unimportant  that  its  restraint 
may  escape  the  attention  of  the  patient  or  parent.  Thus,  in  consider- 
ing early  diagnosis,  and  in  fact,  treatment  and  prognosis,  one  must 
divide  the  spine  into  sections. 


The  divisions  of  the  spine. 


Divisions  of  the  Spine. 

1.  The   neck  part,  that  allows  free  motion  of  the  head,  ending  at 
the  third  dorsal  vertebra. 


DIVISIONS  OF  THE  SPINE. 


31 


2.  The  rigid  thoracic  part  which  includes  the  third  and  the  tenth 
dorsal  seghients. 

Fig.  9. 


^■V> 


Cross-section  of  the  body  of  a  child  at  the  third  dorsal  vertebra.     (Dwight.) 

3.  The  lower  portion  made  up  of  the  two  lower  dorsal  and  the 
lumbar  vertebrae,  in  which  the  principal  movements  of  the  trunk  are 
carried  out.  One  must  bear  in  mind  the  distribution  of  the  nerves, 
because  the  characteristic  pain  is  referred  to  their  terminations,  also 


32  TUBERCULOUS  DISEASE   OF  THE  SPISE. 

the  parts  in  relation  to  the  spine  at  different  levels,  that  may  be  im- 
plicated in  the  disease.  Thus,  remembering  that  the  symptoms  of 
Pott's  disease  are  in  general  stiffness,  weakness,  pain  and  deformity, 
one  will  always  apply  these  symptoms  to  a  particular  region  of  the 
spine,  and  will  picture  to  himself  the  effect  of  such  stiffness,  weakness 
and  deformity  at  this  or  that  vertebra ;  the  effect  of  an  abscess  in  this 
or  that  situation,  and  the  area  of  paralysis  that  might  be  caused  by 
pressure  on  the  cord  at  one  or  another  level. 

Landmarks. — The  atlas  is  on  a  line  with  the  hard  palate. 

The  axis  is  on  a  line  with  the  free  edge  of  the  upper  teeth. 

The  transverse  process  of  the  atlas  is  just  below  and  in  front  of  the 
tip  of  the  mastoid  process. 

The  hyoid  bone  is  opposite  the  fourth  cervical  vertebra. 

The  cricoid  cartilage  is  on  a  line  with  the  sixth  cervical  vertebra. 

The  upper  margin  of  the  sternum  is  opposite  the  disc  between  the 
second  and  third  dorsal  vertebrae. 

The  junction  of  the  first  and  second  sections  of  the  sternum  is  op- 
posite the  fourth  dorsal  vertebra. 

The  tip  of  the  ensiform  cartilage  is  opposite  the  lower  part  of  the 
body  of  the  tenth  dorsal  vertebra. 

The  anterior  extremity  of  the  first  rib  is  on  a  line  with  thf  fourth 
rib  at  the  spine,  the  second  with  the  sixth,  the  fifth  with  the  ninth, 
the  seventh  with  the  eleventh. 

The  scapula  overlaps  the  second  and  the  seventh  ribs,  its  lower  angle 
being  opposite  the  center  of  the  eighth  dorsal  vertebra. 

The  root  of  the  spine  of  the  scapula,  the  glenoid  cavity,  and  the  inter- 
val between  the  second  and  third  dorsal  spines  are  in  the  same  plane. 

The  most  constant  landmark  from  which  to  count,  is  the  spinous  proc- 
ess of  the  fourth  lumbar  vertebra,  which  is  on  a  line  with  the  highest 
point  of  the  crest  of  the  ilium.     The  umbilicus  is  near  the  same  plane. 

The  Inclination  of  the  Pelvis. — In  the  erect  attitude  the  plane  of  the 
brim  forms  an  angle  of  60  to  65  degrees  with  the  horizon. 

The  tip  of  the  coccyx  is  opposite  the  lower  border  of  the  symphysis 
pubis. 

Length  of  the  Spinal  Cord. — In  the  adult  the  spinal  cord  terminates 
at  the  lower  margin  of  the  first  lumbar  vertebra.  At  birth,  it  extends 
to  the  third  lumbar  and  its  membranes  to  the  second  division  of  the 
sacrum. 

The  Intervertebral  Discs. — In  the  adult,  the  intervertebral  discs 
form  41.9  per  cent,  of  the  cervical,  26.4  per  cent,  of  the  dorsal,  and 
44.6  per  cent,  of  the  lumbar  regions  of  the  spine  (Dwight). 

The  Rational  Signs. 

The  symptoms  of  Pott's  disease  vary  decidedly,  not  only  with  the 
region  of  the  spine  involved,  but  also  with  the  age  and  surroundings 
of  the  patient.  Like  other  forms  of  tuberculous  disease  it  is  an  insidi- 
ous chronic  affection  and  its  early  symptoms  may  fiiil  to  attract  atten- 


HISTORY.  33 

tion,  because  they  are  irregular  or  intermittent.  The  child  may  cry 
after  over-exertion  or  injury,  but  afterward  it  may  appear  to  be  in  its 
usual  health,  perhaps  for  days  or  weeks  ;  but  even  during  this  early 
stage,  it  will  be  remembered  afterwards,  that  something  was  "  wrong," 
that  it  was  fretful  and  disinclined  to  play,  that  it  liked  to  lie  on  the 
floor,  that  it  was  awkward  in  its  movements,  that  it  was  troubled  by  a 
cough  or  indigestion,  or  by  oppression  of  breathing.  One,  or  many, 
of  such  symptoms  may  have  existed  for  months,  but,  as  a  rule,  it  is 
not  until  deformity  has  made  the  diagnosis  unmistakable,  that  the 
child  is  brought  for  treatment.  It  is  often  after  a  fall  or  violent  play, 
that  the  evidence  of  pain  or  weakness  can  no  longer  be  overlooked,  so 
that  injury  is  likely  to  occupy  a  prominent  place  in  the  history. 

History. — The  history  of  the  disease  as  obtained  from  the  parent  is 
usually  indefinite  and  misleading.  Certain  points  may  however  be  set 
down  as  of  relative  importance. 

One  will  ask  if  the  immediate  relatives  of  the  child  have  suffered 
from  phthisis  or  other  form  of  tuberculosis,  as  this  might  indicate  a 
predisposition  to  disease,  and  thus  affect  the  prognosis. 

One  asks  if  the  child  has  been  robust  or  the  reverse ;  if  recovery 
from  the  ordinary  ailments  of  childhood  was  prompt  or  tedious,  in 
order  that  one  may  judge  of  the  quality  of  the  patient. 

One  next  asks,  not  "  how  long  has  the  child  been  ill  ?  "  for  this  is 
usually  understood  to  refer  to  the  duration  of  the  more  decided  symp- 
toms, but  "  when  was  the  child  last  perfectly  well  ?  "  One  asks  par- 
ticularly as  to  the  onset  of  the  first  symptoms,  whether  it  was  sharp 
and  decided,  or  gradual  and  ill  defined  ;  if  the  symptoms  were  preceded 
by  contagious  disease.  This  latter  is  an  important  question,  because 
measles,  for  example,  predisposes  to  tuberculous  infection  or  at  least 
to  its  local  outbreak,  and  diphtheria  is  often  followed  by  paralysis  or 
by  weakness,  that  may  simulate  certain  symptoms  of  Pott's  disease. 
The  character  of  the  injury,  that  almost  every  patient  is  supposed  to 
have  received,  is  then  investigated.  It  should  be  made  clear,  whether 
the  injury  was  the  direct  cause  of  the  symptoms  or  if  it  may  have 
simply  aggravated,  or  brought  to  light  the  dormant  disease  or  if,  as  is 
often  the  case,  there  is  simply  an  indefinite  remembrance  of  an  injury 
which  has  no  connection  with  the  symptoms. 

To  establish  injury  as  the  sole  and  direct  cause  of  symptoms,  the 
patient  must  have  been  well  at  the  time  of  the  accident,  the  ■  symp- 
toms must  have  followed  immediately  and  have  continued  since ; 
and  finally  the  symptoms  must  be  of  such  a  nature  as  to  be  explained  by 
a  definite  injury. 

By  careful  questioning  one  may  usually  determine  whether  the 
symptoms  of  which  the  patient  complains  are  acute  or  chronic.  This 
is  of  importance  because  tuberculosis  is  a  chronic  disease,  one  of  the 
few  chronic  diseases  of  childhood,  although  its  exacerbations  may  re- 
semble, in  symptoms,  those  of  acute  disease  or  even  of  injury. 

However  important  a  correct  history  may  be,  the  actual  diagnosis 
depends  entirely  upon  the  physical  examination. 
3 


34    ,  TUBERCULOUS  DISEASE  OF  THE  SPINE. 

Physical  Signs. 

The  physical  examination  begins  on  the  first  sight  of  the  patient, 
when  one  notes  the  general  condition  and  the  actions  and  postures ; 
but  the  ultimate  purpose  is  to  compare  the  appearance  and  mobility  of 
the  spine  suspected  of  disease,  with  the  normal  standard. 

Voluntary  actions  and  attitudes  show  the  adaptation  of  the  body  to 
the  disease,  the  conscious  and  unconscious  efforts  of  the  patient  to 
guard  the  weak  part  from  strain,  and  from  motions  that  cause  discom- 
fort and  pain.  But  by  inspection,  palpation,  and  by  the  tests  of 
voluntary  and  passive  motion,  one  may  demonstrate  and  localize  the 
disease. 

The  examination  must  be  purposeful.  When  one  asks  the  patient 
to  pick  up  a  coin  from  the  floor — the  popular  test  for  Pott's  disease — 
one  employs  it  to  test  the  mobility  of  the  lower  region  of  the  spine, 
the  region  in  which  the  motions  of  stooping  and  turning  the  body  are 
carried  out ;  remembering  that  such  movements  are  often  not  restrained 
in  the  slightest  degree  by  disease  in  the  upper  portion  of  the  spine. 

Such  tests  must  not  only  be  purposeful,  but  they  must  be  adapted 
to  the  age  and  intelligence  of  the  patient.  The  child  that  refuses  to 
pick  up  a  coin  will  often  gather  up  its  clothing,  because  it  wishes  to 
be  dressed  again.  If  it  will  not  stoop,  it  will  usually  rise  if  placed  in 
the  recumbent  or  sitting  posture,  which  is  an  equally  useful  test.  A 
child  will  walk  towards  its  mother,  if  placed  at  a  distance  from  her. 
It  will  always  turn  its  head  towards  her,  thus  voluntary  motion  of 
the  cervical  region  may  be  tested  by  changing  the  mother's  position, 
while  the  child  is  held  by  the  examiner.  Young  children,  who  strug- 
gle and  resist  passive  motion  if  placed  on  the  table,  submit  quietly 
when  held  in  the  motlier's  arms. 

Various  simple  and  effective  tests  will  suggest  themselves  to  the  ex- 
aminer, who  has  a  definite  purpose  in  view,  but  much  patience  may  be 
required  in  early  cases  and  several  examinations  may  be  necessary  be- 
fore the  presence  or  absence  of  disease  can  be  definitely  determined. 
It  is  important  to  remember  that  in  childhood  at  least,  abnormal 
symptoms  always  have  a  cause,  therefore  a  patient  should  always  be 
kept  under  observation  until  the  cause  is  finally  discovered. 

Of  all  the  early  signs  of  Pott's  disease  muscular  rigidity  or  reflex 
muscular  spasm  is  the  most  important,  since  it  precedes  deformity  and 
accompanies  it,  until  cure  is  finally  established.  It  is  a  spasm  that 
resists  motion  in  all  directions  ;  thus  it  may  be  distinguished  from 
the  spasm  or  contraction  of  certain  groups  of  muscles  resulting  from 
irritation  or  inflammation  not  connected  with  the  spine.  For  in  such 
instances  motion  is  limited  only  in  the  directions  directly  opposed  by 
the  muscular  contraction.  True  reflex  muscular  spasm  is  quite  inde- 
pendent of  the  will,  and  thus  it  may  be  easily  distinguished  from  sim- 
ple voluntary  resistance  on  the  part  of  the  patient. 

The  muscular  rigidity  is  most  marked  in  the  neighborhood  of  the 
disease,  but  it  extends  to  a  greater  or  less  distance  according  to  the 


THE  REGIONAL  EXAMINATION.  35 

acuteness  of  the  local  process  and  the  susceptibility  of  the  patient. 
Even  at'  an  early  stage  the  situation  of  the  disease  is  usually  shown  by 
a  slight  irregularity  of  the  spine  in  the  center  of  the  area,  made  rigid 
by  muscular  spasm,  as  well  as  by  the  change  of  contour.  This  change 
in  outline  and  in  flexibility  may  be  demonstrated  by  bending  the 
patient  forward.  If  the  spine  forms  a  long,  even,  regular  curve  and 
if  there  be  no  evidence  of  pain  or  rigidity,  when  such  an  attitude  is 
assumed.  Pott's  disease  is  extremely  improbable.  If,  on  the  other  hand, 
the  outline  of  the  curve  is  broken  ;  if  the  motion  of  one  section  of  the 
spine  is  restrained  by  muscular  rigidity,  disease  may  be  suspected,  and 
if  other  evidence  of  tuberculous  ostitis  is  present,  the  diagnosis  may  be 
made  with  certainty.     (Figs.  6  and  7.) 

By  a  careful  physical  examination  one  may  expect  to  detect  Pott's 
disease  at  any  stage  and  to  fix  upon  its  location,  or  at  least  upon  the 
point  suspected  of  disease.  One  will  then  ask  oneself  if  tuberculous 
disease  of  the  bodies  of  the  vertebrae  of  this  particular  region  will 
satisfactorily  explain  all  the  symptoms  of  which  the  patient  complains  ; 
if  for  example,  the  pain  corresponds  to  the  distribution  of  the  nerves, 
if  restraint  of  function  will  explain  the  attitudes  of  the  patient,  if  the 
change  in  contour  is  significant  of  a  destructive  process,  and  the  like. 

The  principles  of  differential  diagnosis  having  been  outlined  they 
may  be  applied  to  the  detection  of  disease  as  it  appears  in  the  different 
regions  of  the  spine. 

The  Regional  Examination. 

1.  The  Lower  Region. — Considering  the  regions  of  the  spine  in 
the  order  of  liability  to  disease  one  begins  with  the  lower  section  com- 
prising the  lumbar  and  the  two  lower  dorsal  vertebrae,  that  more  nearly 
correspond  in  shape  and  function  to  the  lumbar  than  to  the  thoracic 
division. 

This  is  the  region  of  constant  and  extensive  motion,  thus  the  pain- 
ful rigidity,  characteristic  of  the  disease,  is  often  marked  long  before 
the  stage  of  bone  destruction. 

The  characte7'istiG  attitude  of  the  patient  is  one  of  what  might  be 
called  over-erectness  and  often  there  is  an  increased  holloumess  (lordosis) 
(Figs.  10  and  12)  of  the  back,  so  that  the  prominent  abdomen  may  first 
attract  attention.  The  walk  is  careful,  and  a  peculiar  tip-toeing  step 
with  slight  inversion  of  the  feet  to  avoid  the  jar  of  striking  the  heels 
is  often  observed  ;  this  is  however  not  a  peculiarity  of  disease  of  this  re- 
gion alone,  but  is  rather  an  evidence  that  the  spine  is  sensitive  to  slight 
jars.  More  characteristic  of  lumbar  disease  is  a  peculiar  icaddle,  ex- 
plained in  part  by  the  exaggerated  lordosis,  and  in  part  by  the  loss  of 
the  accommodative,  balancing  motion  of  the  lumbar  spine,  as  the  weight 
falls  alternately  on  each  leg  in  walking. 

The  increased  lumbar  lordosis,  so  characteristic  of  the  early  stage  of 
the  disease,  is  capable  of  several  explanations.  It  is  partly  voluntary  ; 
as  bending  the  body  forward  brings  pressure  upon  the  diseased  verte- 
bral body,  so  bending  it  backward  relieves  this  pressure.     It  is  partly 


36 


TUBERCULOrS  DISEASE   OF  THE  SPINE. 


iiivoluntaiy,  caused  by  the  contraction  of  the  large  muscular  masses 
on  the  posterior  aspect  of  the  spine ;  and  it  is  in  part  compensatory, 
as  the  slight  psoas  contraction  which  is  often  present  has  a  tendency 
to  tilt  the  pelvis  forward,  necessitating  a  greater  compensatory  back- 
ward inclination  of  the  body. 

As  the  disease  progresses,  the  lumbar  section  becomes  straighter, 
and  finally  it  may  project  backward  in  the  characteristic  angular  de- 
formity.    Yet  even  after  the  lordosis  has   been   obliterated  the  back- 


FiG.  10. 


Fig.  11. 


Disease  of  the  upper  lumbar  region  before 
the  stage  of  deformity,  showing  abnormal 
lordosis. 


The  same  patient  (Fig.  10)  five  years 
later  showing  deformity. 


ward  inclination  of  the  body  still  continues  as  a  compensation  for  the 
change  in  Ijalance,  which  the  transformation  of  the  forward  curve  to  a 
posterior  deformity  has  necessitated.  (Fig.  11.)  Thus  over-erectness 
or  Ijackward  inclination  of  the  body  characterizes  the  disease  of  this 
reo-ion  from  its  beginning  to  its  end  in  uncomplicated  cases. 

Slight  psoas  contraction  as  a  part  of  the  general  muscular  spasm 
about  the  point  of  disease,  simply  increases  the  lordosis,  but  if  the 
contraction  is  greater,  when,  for  example,  an  abscess  is  present  which 
involves  the  substance  of  the  psoas  muscles  or  forms  a  painful  tumor 


THE  REGIONAL  EXAMINATION. 


37 


in  the  pelvis,  the  erect  attitude  is  no  longer  possible.  The  legs  are 
drawn  toward  the  body,  and  the  body  is  inclined  forward,  to  relax 
the  tension.  This  greater  contraction,  with  the  abscess  that  is  usually 
its  cause,  is  most  often  limited  to  one  side ;  thus  the  patient  inclines 
the  body  somewhat  forward  and  toward  the  flexed  leg,  "  favors  it " 
and  the   resulting  limp  is  usually  mistaken  for  a  sign  of  hip  disease. 

Fig.  13. 


Fig.  12. 


Diseaseof  the  lumbar  region.     First 
symptom,  pain  in  the  knees. 


Disease  of  lumbar  region  with  right  ilio-psoas  abscess 
and  psoas  contraction. 


Unilateral  psoas  contraction  is,  in  fact,  so  often  present  when  the  pa- 
tient is  first  brought  for  treatment,  that  a  limp  and  the  accompany- 
ing inclination  of  the  body  may  be  considered  as  characteristic  of  dis- 
ease of  the  lumbar  region  at  a  somewhat  later  stage. 

The  location  of  the  pain  depends  upon  the  distribution  of  the  nerves 
that  supply  the  diseased  vertebrae  or  that  pass  in  its  vicinity  ;  it  may 
radiate  over  the  inguinal  region  or  backward  to  the  loins  or  buttocks 


38 


TUBERCULOUS  DISEASE  OF  THE  SPINE. 


Fig.  14. 


or  down  the  front  or  back  of  the  legs  to  the  knees.  Painful  cramp  in 
the  leg  is  sometimes  a  symptom  ;  the  thigh  is  spasmodically  drawn 
toward  the  body  and  the  patient,  seizing  it  with  both  hands,  shrieks 
with  pain. 

Lateral  inclination  of  the  body  is  often  present.  It  is  usually  a 
symptom  of  unilateral  psoas  contraction  and  abscess ;  it  may  be  due 
also  to  unilateral  contraction  of  the  muscles  of  the  back,  or  at  a  later 
stage,  it  may  indicate  collapse  or  destruction  of  one  side  of  a  vertebral 
body.  In  other  instances  it  is  not  a  fixed  attitude,  but  is  simply  a 
voluntary  adaptation  to  weakness  or  pain  ;  thus  one  may  find  a  large 
abscess  in  one  pelvic  fossa  unaccompanied  by  psoas  contraction,  while 
the  body  is  inclined  toward  the  opposite  side,  the  weight  being  borne 

habitually  on  that  leg. 

The  stiffness,  iceakness  and  pain,  char- 
acteristic of  disease  in  this  region  are 
exemplified  in  many  ways,  for  example, 
the  child  maybe  unable  to  turn  in  bed; 
it  is  slow  and  awkward  in  rising  in  the 
morning  or  in  changing  from  an  attitude 
of  rest  to  one  of  activity.  It  often  pre- 
fers to  stand  rather  than  to  sit  because 
in  the  latter  position  more  weight  is 
thrown  upon  the  sensitive  vertebral 
bodies.  When  seated,  particularly  when 
riding  in  a  carriage  or  street  car,  the 
patient  often  sits  upon  the  edge  of  the 
seat,  the  shoulders  only  touching  the 
back,  while  the  hands  rest  instinctively 
on  the  seat,  partially  supporting  the 
weight  and  steadying  the  spine. 

Stooping,  a  posture  that  increases  the 
pressure  on  the  diseased  vertebral  bodies 
and  which  necessitates  muscular  tension 
and  strain  in  regaining  the  erect  posi- 
tion, is  particularly  difficidt  and  it  is 
always  avoided  by  the  patient  if  the 
disease  is  at  all  acute.  For  example  when  the  child  is  asked  to  pick 
up  an  object  from  the  floor,  it  either  refuses,  or  it  squats  on  the  heels 
or  drops  upon  the  knees  (Fig.  14)  instead  of  flexing  the  spine  as  in 
health.  Young  children,  having  seized  the  object  on  the  floor,  regain 
the  erect  attitude  by  pushing  the  body  up  by  the  pressure  of  the  hands 
on  the  thighs.  If  the  child  is  placed  upon  the  floor  it  will,  if  possible, 
seize  the  mother's  dress  or  will  crawl  to  a  chair  or  other  object  upon 
which  the  body  may  be  drawn  up  by  the  arms  so  that  the  discomfort 
caused  by  muscular  contraction  of  the  back  muscles  may  be  avoided. 

After  the  inspection,  and  the  observation  of  the  motions  and  atti- 
tudes of  the  patient,  the  examination  of  the  range  of  passive  motion 
is  made.      The  patient  is  placed  at  full  length  face  downward  on  a 


Lumbar  disease.    The  manner  of  pick- 
ing up  an  object. 


THE  REGIONAL  EXAMINATION. 


39 


table,  and  the  range  of  extension,  and  of  lateral  motion  is  tested  by- 
lifting  tHe  legs  and  swaying  the  body  gently  from  side  to  side.     (Fig. 


Fig.  15. 


Showing  the  rigidity  of  the  spine  before  appearance  of  deformity. 

15.)     The  spine  is  so  flexible  in  childhood,  that  rigidity  even  in  the 
upper  dorsal  region  may  be  demonstrated  by  this  method,  and  in  test- 


FiG.  16. 


Test  for  psoas  contraction. 


ing  the  lumbar  region,  the  thorax  should  be  fixed  by  the  hand  of  the 
examiner.     While  the  patient  remains  in  this  attitude,  one  should  test 


40 


TUBERCULOUS  DISEASE  OF  THE  SPINE. 


for  psoas  contraction ;  the  pelvis  is  pressed  firmly  against  the  table 
with  one  hand,  while  the  leg,  held  in  the  line  of  the  body,  is  gently 
lifted  by  the  other.  (Fig.  16.)  As  tested  in  this  manner,  the 
normal  range  of  extension  should  allow  the  knee  to  be  lifted  two  or 
three  inches  from  the  table.  Slight  restriction  of  extension  of  both 
thighs,  indicating  a  slight  degree  of  psoas  contraction,  is  very  common 
in  lumbar  Pott's  disease,  but  when  the  restriction  is  marked,  and  es- 
pecially if  it  be  unilateral,  a  deep  abscess  may  be  suspected.  Such 
unilateral  psoas  contraction  may  be  more  clearly  demonstrated  by 
placing  the  child  on  the  back,  allowing  the  legs  to  hang  over  the  edge 
of  the  table,  when  the  unaffected  thigh  will  drop  below  its  fellow. 

As  a  rule,  flexion  of  the  lumbar  spine  is  much  more  restricted  in 
the  early  stage  of  the  disease  than  is  extension  ;  this  rigidity  and  fixa- 

FiG.  17. 


A  method  of  demonstrating  psoas  contraction. 


tion  may  be  demonstrated  by  placing  the  child  on  its  hands  and  knees, 
and  lifting  it  from  the  floor ;  when  the  body,  instead  of  bending  over 
the  supporting  hands,  retains  almost  its  original  contour.     (Fig.  18.) 

As  has  been  stated,  even  at  an  early  stage  of  the  disease  one  may 
often  detect  a  slight  fullness  about  the  spinous  processes  or  a  slight 
irregularity  in  their  line,  about  which  the  muscular  spasm  is  most 
marked ;  this  indicates  the  exact  seat  of  the  disease.  Deep  pressure 
on  the  spinous  processes  at  this  point  will  often  cause  pain,  and  some- 
times greater  elasticity  at  the  diseased  area  may  be  demonstrated. 
Except  in  the  hands  of  an  expert,  it  is,  however,  a  test  of  compara- 
tively little  value  ;  and  it  may  be  again  mentioned  that  local  pain  and 
local  sensitiveness  to  pressure  on  the  spinous  processes,  are  not  char- 
acteristic signs  of  Pott's  disease. 

Finally,  one  should  always  examine  for  pdcic  abscess.     This  may 


DIAGNOSIS. 


41 


be  suspected  when  unilateral  psoas  contraction  is  present  in  marked 
degree,  although  psoas  contraction  may  be  present  without  abscess  and 
abscess  may  be  unaccompanied  by  psoas  contraction  when  the  sub- 
stance of  the  muscle  is  not  involved. 

The  typical  psoas  abscess,  as  pictured  and  described,  is  the  fluctu- 
ating tumor,  that  suddenly  appears  on  the  inner  side  of  the  thigh, 
although  it  may  have  been  many  months  in  descending  to  this  position 
from  its  original  site.  Demonstrable  abscess  is  present  at  some  time, 
in  at  least  50  per  cent,  of  the  cases  of  lumbar  disease,  and  its  early 
detection  is  a  matter  of  importance,  since  its  subsequent  behavior  will 

Fig.  18. 


Disease  of  the  lumbar  region  before  the  stage  of  deformity.    A  test  for  rigidity. 


often  materially  influence  the  treatment.  The  child  is  placed  on  the 
side,  the  thigh  is  flexed  and  the  hand  is  pressed  gently  down  into  the 
loin  and  iliac  fossa.  Sometimes  the  examination  will  be  made  easier 
by  extending  the  leg  and  thus  bending  the  spine  forward  toward  tlie 
hand.  Often,  in  this  manner,  one  can  make  out  the  peculiar  sausage- 
like thickening  on  one  or  the  other  side  of  the  spine,  or  a  larger 
rounded  tumor  in  the  iliac  fossa,  the  presence  of  which  would  not 
otherwise  have  been  suspected. 

Diagnosis. — If  a  careful  physical  examination  were  made  in  all 
suspicious  cases,  by  one  at  all  familiar  with  the  ordinary  symptoms  of 


42  TUBERCULOUS  DISEASE  OF  THE  SPINE. 

Pott's  disease,  the  field  for  differential  diagnosis  would  be  small  in- 
deed ;  but  it  would  appear  that  such  examinations  are  not  often  made 
by  the  physician  who  is  first  consulted.  One  is  often  told  that  the 
child  has  been  circumcised  because  of  pain  about  the  genitals,  or  be- 
cause of  weakness  of  the  limbs,  supposed  to  be  due  to  "  refiex  irrita- 
tion ";  or  if  the  patient  be  an  adult,  that  he  has  been  treated  for 
sciatica,  rheumatism  or  strain,  long  after  the  evidence  of  Pott's  dis- 
ease, even  in  the  angular  kyphosis,  would  have  been  apparent  on 
examination. 

Pott's  disease  is  most  often  mistaken  for  some  one  of  the  following 
affections. 

Lumbago — may  simulate  some  of  the  symptoms  of  Pott's  disease 
of  this  region,  but  it  is  an  acute  affection,  of  sudden  onset,  usually 
accompanied  by  local  pain  and  tenderness  of  the  muscles  themselves. 

Strain  of  the  Back — is  often  accompanied  by  stiffness  and  pain  on 
motion,  but  like  lumbago,  its  onset  is  sudden  and  its  cause  is  known. 
The  pain  is  usually  localized  at  the  point  of  injury,  it  is  relieved  by 
rest,  and  the  restriction  of  motion  is,  in  great  degree,  voluntary.  In 
Pott's  disease  the  pain  is  neuralgic  ;  it  is  often  worse  at  night  and 
the  rigidity  is  due  to  reflex  spasm. 

Sciatica. — The  pain  of  sciatica  is  most  often  unilateral ;  it  is  usually 
confined  to  the  distributions  of  this  nerve  which  is  often  sensitive  to 
pressure  throughout  its  course.  The  pain  of  Pott's  disease,  if  it  is  re- 
ferred to  the  legs,  is  usually  bilateral  and  the  nerve  trunks  are  not 
often  sensitive  to  pressure.  In  sciatica,  movements  of  the  leg  that 
cause  tension  on  the  nerve,  are  often  painful,  while  motion  of  the  spine 
is  free,  or  but  slightly  restricted,  the  reverse  of  the  symptoms  of  Pott's 
disease.  It  is  true  that  lateral  deviation  and  even  rigidity  of  the  lum- 
bar spine  are  sometimes  observed  in  cases  of  sciatica  of  long  stand- 
ing, but  if  the  latter  symptom  is  marked,  the  diagnosis  may  be  re- 
garded as  open  to  question.  Sacro-iliac  disease  is  far  more  likely  to 
be  mistaken  for  disease  of  the  hip  than  of  the  spine ;  the  pain  and 
sensitiveness  are  usually  localized  about  the  seat  of  disease  and  the 
motions  of  the  spine  are  not  restricted. 

Lumbago  and  sciatica  and  sacro-iliac  disease  are  extremely  uncom- 
mon in  childhood,  and  if  supposed  strains  or  injuries  of  the  back  cause 
persistent  symptoms,  the  appropriate  treatment  would  be  similar  to  that 
of  Pott's  disease  ;  that  is  to  say,  fixation  and  rest  of  the  suspected  part, 
until  the  cause  of  the  symptoms  is  made  clear. 

The  attitude,  characteristic  of  Pott's  disease  of  this  region,  the 
hollow  back,  the  prominent  abdomen  combined  with  the  waddling 
gait,  may  be  simulated  by  Bilateral  Congenital  Dislocation  of  the  Hip, 
in  which  the  pelvis  is  suspended  at  a  point  behind  its  normal  position, 
but  in  this  deformity  the  gait  and  attitude  have  existed  since  the  child 
began  to  walk,  and  are  accompanied  by  the  symptoms  of  bone  disease. 
A  similar  attitude  is  sometimes  the  result  of  weakness  or  paralysis  of 
the  muscles  of  the  back,  as  for  example  in  Progressive  Muscular  Atro- 
phy,   and  again  in   Pseudo-hypertrophic  Muscular  Paralysis.      In  this 


BIA  GNOSIS. 


43 


latter  affection  there  is  also  a  disinclination  to  stoop,  and  there  may  be 
rigidity  of  the  back,  symptoms  that,  in  the  early  stages,  bear  a  super- 
ficial resemblance  to  Pott's  disease,  but  as  there  are  no  other  signs  of 
disease  of  the  spine,  it  can  be  readily  excluded. 

When  psoas  contraction  is  present  in  lumbar  Pott's  disease,  the  re- 
sulting limp,  that  is  often  accompanied  by  pain  in  the  leg,  is  almost 
invariably  mistaken  for  a  symptom  of  Hip  Disease. 

It  will  be  remembered  that  although  flexion  of  the  leg  caused  by 
psoas  contraction  is  a  common 

symptom  of  Pott's  disease,  it  is  Fig.  19. 

as  a  rule  not  an  early  symp- 
tom; thus  the  history  will  prob- 
ably call  attention  to  symptoms 
referable  to  the  back  that  have 
preceded  it.  Again,  the  limp  of 
Pott's  disease  is  caused  simply 
by  flexion  of  the  leg,  a  limp  that 
is  not,  as  in  joint  disease,  ac- 
companied by  pain  on  functional 
use.  When  therefore,  in  the 
physical  examination,  the  ten- 
sion of  the  contracted  ilio-psoas 
muscle  is  relieved  by  flexing  the 
thigh  still  further,  the  other 
movements  of  the  hip,  flexion, 
rotation  and  the  like,  may  be 
shown  to  be  free  and  unre- 
strained. Thus  hip  disease,  in 
which  all  motions  are  restrained 
in  equal  degree  by  muscular 
spasm,  may  be  easily  excluded, 
except  perhaps  in  infancy. 

Hip  Disease  in  Infancy. — At 
this  susceptible  age  there  is 
almost  always  a  sympathetic 
spasm  of  the  lumbar  muscles  in 
acute  affections  of  the  hip,  and 
similar  spasm  of  the  hip  muscles 
in  disease  of  the  lower  part  of 
the  spine ;  so  that  several  ex- 
aminations may  be  necessary 
before  an  exact  diagnosis  can  be 
made.  In  such  cases  the  application  of  a  temporary  support  to  the 
back  and  leg,  such  as  a  spica  plaster  bandage  which  will  relieve  the 
secondary  spasm,  is  a  useful  aid  in  diagnosis. 

It  has  been  stated  that  extension  of  the  thigh  is  alone  restrained  in 
psoas  contraction  ;  it  will  be  evident,  however,  that  the  presence  of  a 
large  and  painful  abscess  in  the  pelvis  or  thigh  would  limit  motion  in 


Disease  of  the  lower  dorsal  region.    The  earliest 
indication  of  deformity. 


44  TUBERCULOUS  DISEASE  OF  THE  SPINE. 

other  directions  as  well ;  but  even  in  such  cases,  motion  in  one  or  more 
directions  usually  remains  unrestricted ;  thus  disease  within  the  joint 
may  be  excluded. 

Secondary  Hip  Disease. — In  Pott's  disease  of  long  standing  compli- 
cated by  abscess  in  which  the  tissues  about  the  joint  are  infiltrated,  or 
traversed  by  discharging  sinuses,  secondary  infection  of  the  hip  joint 
is  not  an  unusual  complication.  In  such  cases  it  is  not  always  easy  to 
decide  whether  it  is  or  is  not  present,  when  the  limb  is  distorted  and 
when  motion  at  the  hip  is  limited  by  the  infiltrated  and  contracted 
tissues  in  its  neighborhood. 

Pelvic  Abscess. — As  abscess  is  such  a  common  complication  of  Pott's 
disease,  it  will  be  necessary  to  consider  abscesses  of  other  origin,  that 
may  occasionally  cause  symptoms  resembling  somewhat  those  of  dis- 
ease of  the  spine.  Such  are  the  perinej)hritio  abscess,  and  more  rarely, 
that  of  appendicitis.  They  diiFer  from  the  abscesses  of  Pott's  disease  in 
that  they  are,  as  a  rule,  acute  in  their  onset  and  are  accompanied  by 
constitutional  symptoms  and  by  local  pain  and  tenderness.  In  such  cases 
the  motions  of  the  spine  may  be  restrained,  but  the  restraint  is  in  great 
degree  voluntary,  quite  different  from  the  rigidity  due  to  disease  of  its 
substance.  It  is  true  that  the  pelvic  abscess  of  Pott's  disease  which 
has  become  infected  may  cause  constitutional  symptoms,  but  the  history 
of  the  disability  and  discomfort  that  must  have  preceded  the  abscess, 
together  with  the  probable  presence  of  deformity,  will  make  the  diag- 
nosis clear.  Chronic  abscess  in  the  pelvis  of  other  than  spinal  origin, 
may  be  the  result  of  disease  of  the  pelvic  bones,  or  of  the  sacro-iliac 
articulations,  or  of  the  hip  joint.  It  may  be  caused  by  the  breaking 
down  of  lymphatic  glands,  or  it  may  have  its  origin  in  inflammation 
about  the  uterine  appendages  ;  and  cases  of  so-called  idiopathic  in- 
flammation and  suppuration  of  the  ilio-psoas  muscle  have  been  de- 
scribed. In  childhood,  chronic  abscesses  in  this  locality  are  almost 
always  tuberculous  in  character,  and  are  caused  by  disease  of  bone, 
either  of  the  spine  or  of  the  pelvis.  Disease  of  the  spine  can  be  deter- 
mined usually  by  the  methods  already  indicated,  but  if  the  abscess  is  of 
other  origin,  its  exact  cause  can  be  decided  in  many  instances  only  by 
an  operative  exploration.  Abscesses  of  this  character,  of  slow  and 
apparently  painless  formation  may  finally  cause  a  swelling  in  the 
inguinal  region  or  about  the  saphenous  opening,  that  in  the  adult  is 
not  infrequently  mistaken  for  hernia.  In  practically  all  cases,  how- 
ever, the  tumor  of  the  abscess  may  be  made  out  on  palpation  within 
the  pelvis,  while  the  swelling,  although  its  contents  may  be  in  part 
forced  into  the  abdominal  cavity,  is  very  -different  in  feeling  from  the 
complete  reduction  that  is  usually  possible  in  the  ordinary  hernia.  In 
addition  some  sign  of  the  disease  of  the  spine  or  pelvis,  of  which  the 
abscess  is  a  result,  is  almost  always  present. 

Peculiarities  of  Lumbar  Pott's  Disease  in  Infancy. 

Attention  has  been  called  repeatedly  to  the  great  importance  of  the 
careful  observation  of  the  postures  and  movements  of  the  patient,  to 


PECULIARITIES  OF  LUMBAR  POTTS  DISEASE  IN  CHILDREN.    45 

the  change  in  the  contour  of  the  spine  and  particularly  to  the  abnormal 
lordosis  aiid  peculiar  attitude  of  over-erectness  in  the  early  stage  of 
lumbar  disease.  But  the  description  of  attitudes  of  standing  and 
walking,  and  the  shape  of  the  spine  which  is  the  result  of  the  erect 
posture  does  not  apply  to  the  infant  in  arms,  nor  need  the  spine  be 
divided  into  contrasting  sections  for  the  purpose  of  differential  diag- 
nosis. In  Pott's  disease  of  infancy  the  muscular  spasm  is  more  intense 
and  its  extent  is  greater.  The  child  screams  when  it  is  moved  or 
when  the  diapers  are  changed.  There  is  usually  no  difficulty  in  de- 
termining the  presence  of  disease  from  the  evidence  of  rigidity  and 
pain,  but,  as  has  been  mentioned,  it  is  sometimes  difficult  to  decide 
whether  the  lumbar  spine  or  one  of  the  hip  joints  is  involved.  Slight 
irregularity  of  the  spinous  processes  indicating  the  position  of  the  de- 
structive process  is  often  evident  at  an  early  stage  and  early  abscess  is 
not  unusual. 

Pott's  disease  of  infancy  might  be  mistaken  for  acute  rhachitis  or 
scurvy  but  for  the  fact  that  the  symptoms  of  such  affections  are  not 
limited  to  the  spine  but  involve  to  a  greater  or  less  degree  the  limbs 
and  joints,  the  enlarged  epiphyses  and  other  evidences  of  rhachitis  show- 
ing that  the  discomfort  and  pain  are  due  to  a  general,  not  to  a  local  disease. 

The  Rhachitic  Spine. — The  deformity  of  the  spine,  caused  by  rhachitis 
is  not  infrequently  mistaken  for  the  kyphosis  of  Pott's  disease. 

It  has  been  stated  that  a  long  posterior  curvature  of  the  spine  char- 
acterized the  weakness  of  infancy.  It  is  also  characteristic  of  other 
forms  of  weakness  and  particularly  that  caused  by  rhachitis  in  early 
childhood.  During  the  subacute  stage  of  general  rhachitis  the  child 
that  has  never  walked  or  that  has  "  lost  its  walk  "  sits  much  of  the 
time  in  its  chair,  or  is  held  in  this  position  on  the  mother's  arm  so 
that  the  spine  is  bent  backward  and  a  curvature  of  the  lower  thoracic 
and  lumbar  region  is  habitual.  Soon  a  slight  projection  persists,  even 
when  the  child  is  lying  down  ;  it  usually  increases  in  size  and  becomes 
more  rigid  and  permanent,  if  its  exciting  cause  remains  ;  thus  a  some- 
what rounded  and  rigid  posterior  curvature  of  the  dorso-lumbar  por- 
tion of  the  spine  is  formed. 

The  diagnosis  from  Pott's  disease  should  be  made  without  difficulty, 
because  the  evidence  of  general  rhachitis  is  always  present  so  that  such 
deformity  is  almost  as  much  to  be  expected  as  would  be  distortions  of 
the  legs  were  the  child  walking.  If  the  patient  is  placed  in  its-  habit- 
ual sitting  posture  it  will  be  seen  that  the  deformity  is  simply  an  ex- 
aggeration of  a  normal  attitude.  In  this  attitude  the  patient  remains 
contentedly  for  an  indefinite  time,  whereas  if  Pott's  disease  were 
present,  the  child  would  lie  on  its  back  or  abdomen.  Finally,  the 
projection  is  rounded,  not  angular,  and  if  the  patient  be  placed  in  the 
prone  posture  the  projection  may  be  reduced,  in  great  part,  by  raising 
the  thighs  while  gentle  pressure  is  exerted  upon  the  kyphosis ;  and 
although  the  spine  is  somewhat  rigid,  and  although  such  extension  and 
pressure  may  be  resisted  by  the  patient,  yet  there  is  complete  absence 
of  the  muscular  spasm  characteristic  of  Pott's  disease. 


46  TUBERCULOUS  DISEASE  OF  THE  SPINE. 

It  may  be  stated  then  that  the  rhachitic  deformity  is  a  rounded 
curvature  of  the  lower  part  of  the  spine.  Its  cause  is  weakness  and 
habitual  posture.  The  rigidity  depends  upon  the  duration  of  the  de- 
formity. The  pain^  if  the  rhachitis  be  acute^  is  general  and  is  easily 
explained  by  the  sensitive  condition  of  the  bones  and  joints.  It  is 
true  that  rhachitis  and  tuberculous  disease  of  the  spine  may  be  com- 
bined, but  in  such  rare  instances  the  symptoms  of  the  more  serious 
local  disease  will  make  themselves  evident  as  distinct  from  those  of 
the  general  weakness. 

Recapitulation. — The  more  characteristic  symptoms  of  disease  of 
the  dorso-lumbar  region  may  be  summed  up  as  follows  : 

Increased  lordosis  or  over-erectness  and  a  prominent  abdomen  ;  a 
cautious,  constrained  or  waddling  gait ;  less  often,  a  lateral  inclination 
of  the  body,  or  a  limp  caused  by  psoas  contraction. 

Stiffness  of  the  spine,  which  makes  bending  or  turning  the  body 
difficult. 

Pain,  referred  to  the  back,  the  inguinal  region  or  down  the  legs,  and 
in  more  advanced  cases,  the  characteristic  deformity. 

Diagnosis. — The  attitude  may  be  simulated  by  congenital  disloca- 
tion of  the  hips  and  by  pseudo-hypertrophic  muscular  paralysis  or,  more 
rarely,  by  progressive  muscular  atrophy. 

The  limp  may  be  mistaken  for  that 'of  hip  disease. 

The  pain  and  stiffness  for  sciatica,  rheumatism,  lumbago  or  injury. 

The  abscess  is  to  be  distinguished  from  those  from  other  sources. 

In  young  infants  the  symptoms  may  be  simulated  by  hip  disease 
and  by  acute  rhachitis. 

Finally  the  deformity  of  the  subacute  form  of  rhachitis  is  to  be  dis- 
tinguished from  that  symptomatic  of  bone  destruction.  y 

Disease  of  the  Middle  or  Thoracic  Region  of  the  Spine. 

The  normal  motion  of  this  section  of  the  spine,  which  includes  the 
third  and  tenth  vertebrae  is,  as  compared  with  those  above  and  below 
it,  slight ;  thus,  disease  of  this  region  may  not  interfere  to  a  notice- 
able degree  with  the  general  function  of  the  spine. 

As  this  part  of  the  column  curves  backward,  the  deformity,  often 
unattended  by  severe  symptoms,  is  not  infrequently  mistaken  for 
round  shoulders.  It  seems  probable  also,  because  of  the  normal  back- 
ward curve,  and  because  of  the  leverage  exerted  by  the  weight  of  the 
head  and  arms,  that  deformity  quickly  follows  disease.  At  all 
events,  patients  are  not  often  seen  before  it  is  present,  so  that  diag- 
nosis is  usually  evident  on  inspection  of  the  patient. 

The  attitudes  are  not  especially  significant.  If  the  lower  part  of 
this  region  is  involved,  and  if  the  disease  be  at  all  acute,  they  are 
similar  to  those  of  disease  of  the  lower  region,  viz.:  erectness,  the 
peculiar,  cautious,  in-toeing  step,  and  the  disinclination  to  bend  the 
body  forward. 

If,  on  the  other  hand,  the  upper  part  is  affected,  the  attitude  is 


DISEASES  OF  MIDDLE  OR  THORACIC  REGION  OF  SPINE. 


47 


often,  pavticularly  in  young  children,  one  of  weakness ;  there  is  a 
slight  forward  inclination  of  the  body  while  the  head  is  tilted  back- 
ward or  is  inclined  toward  one  side.  A  peculiar  shrugging,  squareness 
and  elevation  of  the  shoulders  is  often  noticed.  (Fig.  21.)  In  many 
instances  the  apparent  elevation  of  the  shoulders  is  in  reality  caused 
by  the  deformity,  which  shortens  the  neck  and  lowers  the  head. 

In  this  connection,  it  should  be  mentioned  that  one  of  the  secondary 

Fig.  21. 


Fig.  20. 


Pott's  disease  of  the  middle  dorsal  region  at 
an  early  stage,  showing  slight  increase  of  the 
dorsal  kyphosis. 


Disease  of  the  upper  dorsal  region. 
Characteristic  attitude. 


effects  of  the  disease,  the  so-called  pigeon  breast,  is,  not  infrequently, 
noticed  by  the  parent  before  the  angular  deformity  of  the  spine.  In 
the  pigeon  breast  of  Pott's  disease,  the  forward  inclination  of  the  spine 
causes  a  flattening  of  the  upper  part  of  the  chest,  while  the  sternum 
sinks  downward  and  becomes  prominent,  thus  the  antero-posterior 
diameter  of  the  chest  is  increased,  and  it  is  compressed  from  side  to 
side,  so  that  it  resembles  very  closely  the  deformity  of  rhachitis.     As 


48 


TUBERCULOUS  DISEASE  OF  THE  SPINE. 


the  pigeon  breast  of  Pott's  disease  is  always  secondary  to  the  deformity, 
its  cause,  of  course,  becomes  apparent  on  examining  the  spine. 

Of  the  early  symptoms  of  dorsal  disease,  pain  and  labored  or 
'^ grunting"  respiration  are  the  most  characteristic.  Pain  referred  to 
the  abdomen  and  to  the  front  and  sides  of  the  chest  is  usually  an  early 
and  often  a  constant  symptom  ;  thus  persistent  "  stomach-ache  "  in  a 
child  should  always  lead  one  to  an  examination  of  the  spine.     A 

"  spasm  of  pain  "  is  sometimes  excited  by 
Pj(,    22  lateral  compression  of  the  chest,  as  when 

the  child  is  lifted  suddenly  by  the  parent. 
Of  much  greater  importance,  however, 
is  the  labored  or  grunting  respiration,  which 
indeed  is  almost  pathognomonic  of  Pott's 
disease.  This  ^'grunting"  is  caused  by 
the  interference  with  respiration,  more  par- 
ticularly with  the  normal  rhythmical  move- 
ments of  the  ribs.  The  restraint  is,  in  part, 
due  to  muscular  spasm,  and  in  part  to  the 
voluntary  eiforts  of  the  patient.  The  in- 
spiration is  quick  and  shallow,  in  great 
degree  diaphragmatic,  and  expiration  is 
accompanied  by  a  sigh  or  grunt.  This  is 
apparently  caused  by  a  momentary  closure 
of  the  larynx  to  resist  the  escape  of  air  and 
thus  sudden  motion  of  the  chest  wall. 
Grunting  respiration  is,  of  course,  an  evi- 
dence of  the  more  acute  type  of  disease,  but 
even  in  mild  cases  in  children  it  will  be 
noticed  when  the  patient  is  fatigued,  or 
during  play. 

All  irritating,  aimless  cough  is  often  a 
symptom  of  disease  of  the  upper  dorsal 
region,  and  spasmodic  attacks  resembling 
asthma  are  not  uncommon. 

The  physical  examination  will,  in  most 
cases,  show  the  characteristic  angular  ky- 
phosis, and  in  the  exceptional  cases,  in 
which  deformity  is  absent,  a  slight  change 
in  contour  will  be  apparent  when  the  pa- 
tient is  bent  forward.  In  place  of  the  long 
regular  curve  of  the  normal  spine,  a  point 
where  two  distinct  outlines  unite  will  be  observed,  one  of  which  may 
be  curved  while  the  other  is  practically  straight. 

The  presence  of  muscular  spasm  may  be  shown  by  sudden  move- 
ment of  the  spine,  and  it  may  also  be  demonstrated,  in  children,  by 
raising  the  legs  and  swaying  the  body  from  side  to  side,  as  illustrated 
in  the  preceding  section.  (Fig.  15.)  The  change  in  the  rhythm  of 
respiration  has  already  been  mentioned  ;  the  restraint  does  not  affect 


Marked  lateral  deviation  of  the 
spine  with  rotation.  Deformity  at 
the  eighth  dorsal  vertebra. 


DISEASE  OF  MIDDLE  OR  THORACIC  REGION  OF  SPINE. 


49 


the  motion  of  all  the  ribs  equally,  those  that  articulate  with  the  diseased 
vertebrae  -;are  often  nearly  motionless  while  the  movement  of  those  at  a 
distance  may  approach  the  normal. 

In  tracing  the  neuralgic  pain  to  its  origin,  the  sharp  downward  in- 
clination of  the  ribs  must  be  borne  in  mind  ;  thus,  the  cause  of  pain 
in  the  "  stomach  "  must  be  looked  for  between  the  shoulder  blades. 

As  in  the  lumbar  region,  slight  lateral  deviation  of  the  spine  is  not 
uncommon,  and  it  may  be  accompanied  by  a  slight  twist  or  rotation  so 
that  the  ribs  on  one  side  are  more  prominent.     (Fig.  22.) 

Fig.  23. 


Double  psoas  contraction  of  an  extreme  degree  and  paralysis.    The  arms  used  as  supports. 


In  disease  of  this  region  of  the  spine  the  spinal  cord  is  more  often 
involved  than  elsewhere,  thus  an  awkward  stumbling  gait  and  finally 
a  "  loss  of  walk "  may  be  the  symptoms  that  first  attract  attention. 
This  paralysis  of  Pott's  disease  and  its  differential  diagnosis  are  con- 
sidered elsewhere. 

Abscess  as  a  complication,  can  not  be  demonstrated  by  palpation 

unless  it  has  found   an  outlet  between  the  ribs,  but  percussion  will 

often  show  an  area  of  dullness  or  flatness,  extending  from  the  diseased 

vertebrae  toward  the  lateral  aspect  of  the  chest,  due  in  part,  however, 

4 


50  TUBERCULOUS  DISEASE  OF  THE  SPINE. 

to  the  inflammatory  thickening  of  the  tissues  in  the  neighborhood. 
In  rare  instances  the  abscess  may  press  directly  upon  the  trachea  or 
bronchi  and  cause  spasmodic  attacks  of  dyspnoea  resembling  asthma. 
Diagnosis. — It  is  hardly  necessary  to  mention  the  list  of  aifections 
that  may  cause  pain  in  the  chest  or  abdomen  ;  it  is  sufficient  to  state 
that  such  symptoms  always  require  a  physical  examination.  The  same 
statement  applies  to  irregular  respiration,  to  cough  and  so-called  asthma. 

Occasionally  tuberculous  disease  of  the  dorsal  spine  in  adolescence, 
is  not  only  practically  painless,  but  the  resulting  deformity  is  rather 
rounded  than  angular,  so  that  it  may  be  mistaken  for  round  shoulders. 
"  Round  shoulders  "  is  however,  as  a  rule,  of  longer  duration  ;  some 
exciting  cause  of  postural  deformity,  in  occupation  or  otherwise,  is 
usually  apparent ;  while  the  rigidity  is  less  marked  than  in  Pott's  dis- 
ease and  pain  is  absent. 

The  situation  and  shape  of  the  rhachitic  kyphosis  has  been  de- 
scribed. It  should  be  evident,  that  a  more  or  less  angular  projection, 
in  the  upper  part  of  the  spine  could  not  be  rhachitic,  and  yet  because 
of  the  absence  of  pain,  this  diagnosis  is  not  infrequently  made,  and  as 
a  consequence,  the  activity  of  the  tuberculous  disease  may  be  increased 
by  massage  and  exercises. 

Lateral  deviation  of  the  spine  as  a  symptom  of  disease,  could  not 
be  mistaken  for  the  ordinary  rotary-lateral  curvature,  in  which  pain  and 
muscular  rigidity  are  absent. 

Acute  affections  within  the  chest,  pleurisy,  pneumonia  and  empyema 
are  sometimes  accompanied  by  lateral  deviation  of  the  spine,  but  the 
sudden  onset,  and  the  constitutional  and  local  symptoms  that  accom- 
pany such  affections  should  make  the  cause  of  the  deformity  and  pain 
evident.  It  is  because  these  cases  are  sometimes  sent  to  orthopaedic 
clinics  for  braces  that  such  causes  of  deformity  seem  worthy  of  men- 
tion. 

The  abscess  of  Pott's  disease  in  this  region,  as  has  been  mentioned, 
causes  dullness  or  flatness  on  percussion  of  the  chest  and  within  this 
area  friction  sounds  and  rales  may  be  heard. 

If  the  diagnosis  of  Pott's  disease  had  not  been  made  or  if  the  pres- 
ence of  the  abscess  had  not  been  determined  by  the  previous  physical 
examination,  it  might  be  mistaken,  during  an  acute  exacerbation  of 
the  disease  or  constitutional  disturbance  from  other  cause,  for  pleurisy 
or  empyema,  and  at  other  times  for  phthisis.  The  tuberculous  fluid 
may  remain  indefinitely  in  the  posterior  mediastinum  and  the  area  of 
flatness  may  extend  beyond  the  axillary  line,  yet  it  may  give  rise  to 
no  symptoms. 

In  all  cases  then,  a  careful  examination  of  the  chest  should  be  made 
from  time  to  time  in  order  that  the  presence  or  absence  of  abscess  may 
be  recorded. 

Recapitulation. — Pott's  disease  of  this  region  is  often  insidious  in 
its  onset,  causing  no  positive  symptoms  before  the  stage  of  deformity. 

Its  most  characteristic  symptoms  are  pain  referred  to  the  front  and 
sides  of  the  body  and  the  grunting  respiration. 


THE   UPPER  REGION. 


51 


If  the  disease  is  progressive  the  ordinary  symptoms  of  Pott's  disease 
— weakness  and  rigidity — are  present ;  in  the  lower  thoracic  region, 
the  attitude  resembles  that  of  lumbar  disease ;  in  the  upper,  the  head 
is  usually  tilted  somewhat  backward  and  the  shoulders  appear  to  be 
elevated. 

In  differential  diagnosis,  one  will  consider  the  significance  of  pain, 
the  cough  or  embarrassed  respiration  and  the  affections  for  which  ab- 
scess or  paralysis  might  be  mistaken. 

Also  round  shoulders,  rhachitic  deformity  and  lateral  deviation  of 
the  spine  as  distinguished  from  the  kyphosis  of  Pott's  disease. 

The  Upper  Region. 

The  upper  region  of  the  spine,  which  includes  the  cervical  and  two 
of  the  dorsal  vertebne,  corresponds  in  freedom  of  motion  and  in  the 
forward  curve,  to  the  lumbar  region.     For  the  purpose  of  study,  it 

Fig.  24. 


Cervical  disease  with  abscess.    Characteristic  attitude. 

must  be  divided  into  two  parts.  Of  these,  the  superior  or  occipito- 
axoid  section  is  peculiar,  in  that  it  contains  no  vertebral  body  or  inter- 
vertebral cartilage,  and  in  that  the  movements  of  the  head  are  carried 
out  in  special  joints  and  are  controlled  by  special  muscles. 


52  TUBERCULOUS  DISEASE  OF  THE  SPINE. 

Disease  at  this  point  is  especially  dangerous,  because  displacement 
or  fracture  of  the  weakened  vertebrae  may  cause  sudden  death  by  pres- 
sure on  the  vital  centers. 

Occipito-axoid  disease  is  comparatively  rare,  and  it  is  relatively 
more  frequent  in  adult  life  than  in  childhood. 

Symptoms. — In  a  typical  case,  the  symptoms  are  neuralgic  pain 
radiating  over  the  back  and  sides  of  the  head,  following  the  distribu- 
tion of  the  auricular  and  occipital  nerves.  The  neck  is  stiff  and  the 
head  may  be  fixed  in  the  median  line,  the  chin  being  somewhat  de- 
pressed, but  it  is  more  often  tilted  to  one  side,  simulating  the  attitude 
of  torticollis.     (Fig.  24.) 

The  attitude  and  appearance,  when  normal  movement  of  the  neck  is 
cut  off  by  a  painful  disease  is  characteristic ;  the  eyes  follow  one,  or 
the  body  is  turned,  when  the  attention  of  the  patient  is  attracted.  The 
patient  moves  carefully,  in  order  to  avoid  jar ;  often  the  chin  is  instinc- 
tively supported  by  the  hand,  and  a  favorite  attitude  is  one  in  which 
the  patient  sits  with  the  elbows  on  a  table,  the  hands  supporting  the 
head.  (Fig.  25.)  If  the  attempt  is  made  to  raise  the  chin,  or  to  ro- 
tate the  head,  the  patient  seizes  the  hands  of  the  examiner  and,  if  a 
child,  it  screams  in  apprehension.  There  is  often  a  slight  bulging  and 
thickening  of  the  tissues  at  the  seat  of  disease.  The  affected  vertebrae 
are  usually  sensitive  to  deep  pressure,  and  not  infrequently,  deep  fluc- 
tuation in  the  sub-occipital  triangle  can  be  made  out. 

The  atlo-axoid  junction  lies  just  behind  the  posterior  wall  of  the 
pharynx  on  a  line  with  the  upper  teeth  and  here  abscess  often  presents 
itself,  occasionally  early  in  the  course  of  the  disease,  causing  symptoms 
characteristic  of  obstruction,  such  as  snoring,  change  in  the  quality  of 
the  voice,  difficulty  in  swallowing,  and  sometimes  spasmodic  attacks  of 
so-called  croup.  When  abscess  is  present  and  when  the  disease  is  at 
all  acute,  the  reclining  posture  sometimes  aggravates  the  symptoms,  so 
that  "  getting  the  child  to  bed  "  is  often  a  tedious  and  difficult  task. 

In  certain  cases,  one  may  make  out  the  exact  location  of  the  disease 
in  the  occipito-atloid  or  the  atlo-axoid  articulation,  but  as  both  joints 
are  to  a  great  extent  controlled  by  the  same  muscles,  this  is  often  im- 
possible when  muscular  spasm  is  well  marked. 

The  uppermost  joint,  that  between  the  atlas  and  occiput  permits  the 
nodding  movement  of  the  head,  or  flexion  and  extension  on  the  spine  ; 
while  the  atlo-axoid  joint  permits  rotation  of  the  atlas  about  the  axis 
to  the  extent  of  about  30  degrees  in  either  direction.  If  the  disease 
be  in  the  upper  joint  the  nodding  movements  will  be  more  restricted 
than  those  of  rotation  and  vice  versa.  The  motion  of  the  entire  cer- 
vical spine  is  very  free  so  that  to  make  the  test  one  must  grasp  the 
neck  firmly,  in  order  to  restrain  motion  except  in  the  joint  under  ex- 
amination. Because  of  this  freedom  of  movement,  restriction  of  mo- 
tion, symptomatic  of  disease  in  the  upper  region,  is  often  overlooked 
when  it  is  of  the  sub-acute  variety. 

The  Lower  Cervical  Region. — The  symptoms  of  disease  of  the  lower 
cervical  section,  although  similar  in  character,  are  often  less  marked 


SYMPTOMS. 


53 


than  those  of  the  upper  region.  The  cervical  spine  becomes  straighter 
and  often  a  slight  backward  projection  or  thickening  indicates  the  posi- 
tion of  the  disease.  The  head  is  usually  turned  to  one  side  by  spasm 
of  the  lateral  muscles  in  an  attitude  of  wry  neck.  (Fig.  26.)  The 
pain  is  referred  to  the  neck,  to  the  sternal  region  or  down  the  arms, 
following  the  distribution  of  the  brachial  plexus. 

Fig.  25. 


Cervical  disease.    A  characteristic  attitude. 

In  cases  of  more  advanced  disease,  one's  attention  may  be  attracted 
to  the  cervical  region,  because  the  neck  seems  short  and  because  the 
head  is  tilted  backward.  The  entire  back  shows  a  compensatory  flat- 
tening, yet  no  deformity  is  apparent  until  the  occiput  is  raised  and 
drawn  forward,  when  a  shelf-like  projection  may  be  felt,  at  what  ap- 
pears to  be  the  top  of  the  spine,  but  which  is  really  the  angular  de- 
formity at  the  third  or  fourth  vertebra. 

This  emphasizes  the  importance  of  a  careful  observation  of  the  con- 
tour of  the  spine  and  the  necessity  of  explaining  to  oneself  every 
change  from  the  normal  that  may  be  noticed. 

Disease  at  the  cervico-dorsal  junction  resembles  in  its  symptoms  that 
of  the  upper  dorsal  region.  The  head  is  usually  tilted  backward  (Fig. 
21)  or  it  may  be  turned  to  one  side.     Disease  at  this  point  is  often  sub- 


54 


TUBERCULOUS  DISEASE  OF  THE  SPINE. 


Fig.  26. 


acute  in  character,  and  paralysis  from  implication  of  the  spinal   cord 
sometimes  appears  before  deformity  is  apparent. 

The  seventh  cervical  or  first  dorsal  spine  is  often  prominent  (verte- 
bra prominens)  in  normal  individuals  and  it  may  be  mistaken  for  the 
deformity  of  disease,  especially  when  pain  about  this  point  is  a  symp- 
tom, as  in  hysterical  or  hypersesthetic  persons.  If  such  projection  is 
symptomatic  of  disease  there  is  almost  always  a  slight  compensatory 
flattening  of  the  spine  below  the  point  and  a  certain  amount  of  rig- 
idity of  the  surrounding  muscles. 

Diagnosis. — As  stiffness  and  distortion  of  the  neck  are  the  most 
prominent  symptoms  of  disease  of  this  region  it  will  be  necessary  to 
consider  first,  the  forms  of  Torticollis  for  which  it  might  be  mistaken. 
In  typical  torticollis  or  wry  neck,  the  distortion  of  the  head  is  caused, 

almost  invariably,  by  contraction  of 
the  muscles  supplied  by  the  spinal 
accessory  nerve,  the  sterno-mastoid 
and  trapezius,  so  that  the  chin  is 
slightly  elevated  and  turned  away 
from  the  contracted  muscle. 

Congenital  Torticollis  which  has  ex- 
isted from  birth  is  not  accompanied 
by  pain  and  it  could  hardly  be  mis- 
taken for  a  symptom  of  disease. 

Acute  rheumatic  Torticollis,  "  stiff 
neck,"  is  sufficiently  common  to  be 
familiar  in  its  characteristics.  It  is 
of  sudden  onset,  "  in  a  single  night"; 
the  affected  muscles  are  sensitive  to 
pressure ;  the  course  of  the  affection 
is  short,  and  it  is  of  comparative  in- 
significance. 

A  more  persistent  form  of  acute 
torticollis,  accompanied  by  greater 
muscular  spasm  and  by  local  tender- 
ness, sometimes  follows  of  enlarged  or  suppurating  cervical  glands;  it 
may  follow  "  earache,"  tonsilitis  or  sore  throat  or  any  form  of  irritation 
about  the  pharynx.  This  form  of  wry  neck  is  not  only  more  painful, 
but  it  may  last  indefinitely,  and  permanent  deformity  may  result.  The 
onset  is  usually  sudden ;  the  pain  and  tenderness  are  local,  and  are 
confined,  as  a  rule,  to  the  contracted  part.  The  sterno-mastoid  and 
trapezius  muscles  are  most  often  involved,  thus  the  wry  neck  is  typical. 
If  the  tension  be  relaxed  by  inclining  the  head  toward  the  contracted 
muscle,  motion  of  the  spine  itself  will  be  found  to  be  free  and  painless, 
but  if  traction  be  made  on  the  contracted  muscle,  it  causes  discomfort, 
thus  it  is  usually  resisted  by  the  patient. 

In  disease  of  the  occipito-axoid  region,  the  distortion  of  the  head  is, 
by  no  means,  typical  of  sterno-mastoid  contraction  ;  it  may  be  tilted 
up  or  down  or  laterally  to  an  exaggerated  degree.     In  other  words, 


Disease  of  the  middle  cervical  region  at  an 
early  stage. 


DIAGNOSIS.  55 

the  wry  neck  of  Pott's  disease  is  an  irregular  distortion,  not  dependent 
on  the  6ontraction  of  a  particular  muscle  or  muscular  group.  "  In 
torticollis  the  chin  is  turned  away  from  the  contracted  muscle  while  in 
Pottos  disease  it  is  turned  toward  the  contracted  muscle."  This  is  an 
axiomatic  expression  of  the  fact  that  the  distortion  of  the  head  symp- 
tomatic of  atlo-axoid  disease,  depends,  in  great  degree,  upon  the  spasm 
of  the  small  muscles  that  directly  control  these  joints,  the  recti  and 
obliqui  and  not  directly  upon  the  contraction  of  the  sterno-mastoid 
muscle,  as  in  the  ordinary  form  of  wry  neck.  Again  the  contraction, 
symptomatic  of  Pott's  disease,  of  this  or  other  regions,  is  the  result  of 
muscular  spasm,  a  muscular  spasm  that  fixes  the  head  and  prevents 
painful  motion.  If  the  head  be  grasped  firmly  by  the  hands  and  if 
gentle  traction  be  made,  the  muscular  spasm  relaxes  and  the  patient 
experiences  a  sensation  of  comfort,  while  if  similar  traction  is  made 
upon  the  contracted  muscles  of  simple  wry  neck,  the  pain  is  increased 
and  the  patient  protests. 

In  disease  of  the  middle  cervical  region,  however,  the  distortion  due 
to  the  reflex  muscular  spasm,  is  similar  to  that  of  simple  torticollis,  and 
it  is  sometimes  difficult  to  distinguish  one  from  the  other,  particularly 
if  the  latter  is  caused  by  the  irritation  of  inflamed  or  suppurating 
glands.  For,  in  such  cases,  there  is  usually  much  sensitiveness  to 
manipulation  and  a  more  or  less  general  muscular  spasm,  so  that  diag- 
nosis may  be  impossible,  until  apparatus  has  been  applied  to  rest  the 
part,  and  to  correct  the  deformity. 

It  has  been  stated  that  the  head  was  often  tilted  backward  to  com- 
pensate for  deformity  in  the  middle  cervical  region.  It  is  also,  in 
some  instances,  drawn  backward  by  spasm  of  the  posterior  muscles. 
Such  a  case  might  be  mistaken  for  cervical  opisthotonos,  in  which  the 
head  is  held  in  an  over-extended  position,  as  is  sometimes  seen  in 
young  infants  suffering  from  exhausting  diseases,  basilar  meningitis 
and  the  like.  In  such  conditions,  however,  the  characteristic  symp- 
toms of  Pott's  disease  are,  of  course,  absent. 

The  opposite  attitude,  viz.,  a  forward  droop  of  the  head  due  to  weak- 
ness of  the  trapezii  muscles,  is  not  uncommon  as  a  sequence  of  diph- 
theria or  other  forms  of  contagious  disease.  This  droop  may  be 
accompanied  also  by  spasm  of  one  of  the  sterno-mastoid  muscles  and 
by  pain.  In  such  cases,  the  history  of  the  preceding  affection,  the 
weakness  or  paralysis  of  other  parts,  as  of  the  soft  palate,  the  muscles 
of  accommodation  of  the  eye  and  the  like,  together  with  the  general 
bodily  weakness  that  the  patients  often  present,  should  make  the  diag- 
nosis clear. 

Injury  to  the  upper  segment  of  the  spine,  a  sprain,  contusion,  or 
fracture  unless  efficiently  treated,  may  cause  symptoms  resembling  very 
closely  those  of  tuberculous  disease ;  for  example,  the  pain  often  radi- 
ates over  the  back  of  the  head,  and  there  may  be  rigidity  and  deform- 
ity of  the  neck,  and  even  infiltration  and  local  tenderness  about  the  in- 
jured part.  Such  cases,  when  seen  several  weeks  or  months  after  the 
accident,  are  puzzling,  because  one  may  be  in  doubt  whether  the  symp- 


56  TUBERCULOUS  DISEASE  OF  THE  SPINE. 

toms  were  caused  by  a  simple  injury  or  whether  tuberculous  infection 
may  have  followed  or  preceded  it.  In  such  cases  a  positive  diagnosis 
cannot  be  made  until  the  effect  of  rest  and  protection  has  been  observed, 
that  is  to  say,  suspicious  cases  should  be  treated  as  one  would  treat 
actual  disease.  If  the  case  is  simply  one  of  injury,  recovery  will  be 
rapid  and  complete,  while  if  disease  be  present,  the  symptoms  only, 
will  be  relieved. 

The  occipito-axoid  articulation  may  be  involved  in  acute  articular 
rheumatism,  or  in  chronic  rheumatoid  arthritis,  when  the  diagnosis  is  of 
course  easily  made,  but  occasionally  the  joints  at  the  upper  extremity 
of  the  spine  may  be  the  seat  of  what  appears  to  be  an  infectious  arth- 
ritis, in  which  the  symptoms  are  of  sudden  onset  and  are  sometimes 
combined  with  fever  and  constitutional  disturbance,  and  in  which  no 
other  joint  is  involved.  The  sudden  onset  and  the  rapid  recovery  are 
the  diagnostic  points. 

Abscess  in  the  cervical  region  is  a  secondary  symptom,  and  although 
it  may  first  attract  attention  to  disease  by  the  change  in  the  voice  or 
the  difficulty  in  breathing  or  swallowing,  yet  it  is  always  accompanied 
by  some  of  the  characteristic  signs  of  Pott's  disease. 

Whenever  the  diagnosis  of  cervical  disease  is  made,  one  should  ex- 
amine the  throat,  and  whenever  a  chronic  retro-pharyngeal  abscess  is 
present  one  should  look  for  the  symptoms  of  Pott's  disease. 

The  diagnosis  of  the  retro-pharyngeal  abscess  can  be  made  only  by 
inspection  and  palpation  ;  therefore,  one  need  only  mention  the  fact, 
that  symptoms  of  obstruction  in  the  throat,  similar  to  those  of  abscess, 
may  be  caused  by  adenoid  growths  and  enlarged  tonsils. 

Retro-pharyngeal  abscess  is  by  no  means  always  symptomatic  of 
Pott's  disease.  It  may  be  acute,  as  one  of  the  sequelae  of  contagious 
disease  or  as  a  complication  of  pharyngitis.  It  is  then  rapid  in  its 
onset  and  is  not  accompanied  by  the  symptoms  of  Pott's  disease. 

Recapitulation. 

If  the  disease  is  of  the  upper  or  occipito-axoid  region  the  head  is 
usually  fixed  in  an  attitude  of  deformity,  which  is  sometimes  slight 
and  sometimes  extreme. 

In  the  middle  region,  the  attitude  more  often  resembles  that  of  or- 
dinary torticollis.  In  the  lower  region,  there  is  often  no  marked 
spasm  of  muscles,  but  the  head  hangs  backward  or  toward  one 
shoulder. 

The  contour  of  the  cervical  spine  changes  as  the  disease  progresses, 
the  normal  anterior  curvature  is  obliterated,  thus  the  head  is  pushed 
forward,  while  the  dorsal  section  of  the  spine  becomes  flat  or  even  in- 
curvated  in  compensation.  The  seat  of  the  disease  is  often  shown  by 
an  area  of  thickening  or  local  tenderness  to  deep  pressure. 

Disease  of  the  joints  of  the  upper  or  occipito-axoid  section  is  often 
acute  in  onset,  sometimes  a  form  of  synovial  tuberculosis,  and  abscess 
is  a  very  frequent  complication. 


THE  RECORD    OF  THE  CASE.  57 

Differential  diagnosis  of  disease  in  this  region  will  include  the  con- 
sideration 'Of  the  various  forms  of  wry  neck,  cervical  opisthotonos, 
diphtheritic  paralysis,  and  injury.  Retro-pharyngeal  abscess  must  be 
distinguished  from  that  not  connected  with  the  bone,  and  from  other 
forms  of  obstruction  in  the  throat. 

Diagnosis  in  General. 

Weakness  and  the  so-called  "  loss  of  walk  "  are  well-known  symp- 
toms of  Pott's  disease,  and  on  this  account  children  suffering  from 
different  forms  of  weakness  or  paralysis  are  often  sent  to  orthopaedic 
clinics  for  the  treatment  of  "  spine  disease." 

Certain  forms  of  paralysis  bear  a  superficial  resemblance  to  some  of 
the  symptoms  of  Pott's  disease,  for  example  pseudohypertrophic  mus- 
cular paralysis  to  the  attitude  caused  by  disease  of  the  lumbar  region 
and  diphtheritic  paralysis  to  that  of  the  dorsal  region.  Spastic  par- 
alysis, of  cerebral  origin,  resembles  somewhat  the  paralysis  of  Pott's 
disease,  but  it  may  be  differentiated  by  tlie  absence  of  pain,  by  the 
history  and  by  what  is  apparent  in  most  cases,  the  mental  impairment. 

The  contractions  combined  with  the  weakness  and  pain  that  some- 
times follow  cerebro-spinal  meningitis  may  be  mistaken  for  the  symp- 
toms of  bone  disease,  but  are  as  a  rule  readily  explained  by  the  history 
of  the  case. 

Forms  of  organic  disease  of  the  spine,  other  than  tuberculous,  as,  for 
example,  malignant  disease,  syphilis  and  the  like,  are  described  in 
Chapter  II. 

The  list  of  affections  that  has  been  considered  in  the  differential 
diagnosis,  is  a  long  one,  but  it  has  been  made  up  from  actual  experi- 
ence. Most  mistakes  in  diagnosis  may  be  explained  by  carelessness  or 
ignorance,  or  because  of  insufficient  opportunity  for  examination  ;  but 
in  the  earliest  stages  of  the  disease,  repeated  examinations,  time  for 
observation  and  even  tentative  treatment  may  be  necessary  before  the 
diagnosis  is  confirmed. 

The  Roentgen  Ray  Photography  as  a  Means  of  Diagnosis. — The 
Roentgen  ray  is  of  value  as  a  means  of  determining  the  exact  extent 
of  the  disease.  If  the  negative  is  well  defined,  the  diseased  vertebrae 
are  seen  to  be  irregular  in  outline  or  they  may  be  lost  in  a  peculiar 
blur.  By  counting  from  above  and  below  the  exact  extent  of  the 
disease  may  be  made  out,  but  inferences  as  to  its  character  and  quality 
must  be  made  from  the  rational  and  physical  signs. 

The  Record  of  the  Case. 

The  history  and  the  result  of  the  examination  of  the  patient  should 
be  recorded  somewhat  in  the  following  order. 

1.  The  family  and  the  personal  history. 

2.  The  story  of  the  disease  with  especial  reference  to  its  mode  of  onset, 
its  probable  duration,  to  the  noticeable  symptoms  and  to  previous 
treatment,  if  any. 


58  TUBERCULOUS  DISEASE  OF  THE  SPINE. 

3.  The  physical  examination.  This  should  include  the  general 
condition  of  the  patient ;  the  height  and  weight ;  the  attitude ;  the 
character  of  the  disease,  whether  acute  or  otherwise,  as  shown  by  the 
muscular  spasm  and  pain  on  motion ;  the  presence  of  abscess  as  a 
complication,  or  paralysis ;  and  finally,  the  position  and  extent  of  the 
disease.  This  is  best  shown  by  a  tracing,  made  by  means  of  a  strip 
of  lead  or  pure  tin  of  such  thickness  that  it  may  be  readily  moulded 
on  the  spine  and  yet  hold  its  shape  when  removed.  Young's  de^dce, 
consisting  of  movable  pins  set  in  a  frame,  is  a  serviceable  appliance 
for  this  purpose. 

The  tracing  should  be  of  the  entire  spine,  made  while  the  patient 
lies  extended  in  the  prone  position,  and  the  exact  location  of  the 
most  prominent  spinous  processes  should  be  marked  upon  it.  In 
determining  the  position  of  the  disease  it  is  well  to  count  the  spin- 
ous processes  from  below  upward,  beginning  with  that  of  the  fourth 
lumbar  vertebra,  which  lies  on  a  line  drawn  between  the  highest 
points  of  the  iliac  crests.  There  are  other  landmarks  that  are  ap- 
proximately correct.  Sometimes  the  last  rib  may  be  traced  to  its 
origin,  the  scapula  covers  the  second  and  seventh  ribs,  the  root  of  the 
spine  of  the  scapula  and  the  middle  point  of  the  glenoid  cavity  being 
on  a  line  with  the  third,  and  its  inferior  angle  opposite  the  tip  of  the 
seventh  dorsal  spinous  process.  The  upper  margin  of  the  sternum  is 
opposite  the  interval  between  the  second  and  third  dorsal  vertebrae. 
The  vertebra  prominens  can  often  be  distinguished,  as  may  the  spinous 
process  of  the  axis. 

Such  landmarks  are,  of  course,  somewhat  displaced  in  deformity, 
but  they  are  always  sufficiently  correct  to  check  errors  in  counting  the 
spinous  processes. 

The  history  furnishes  a  foundation  on  which  treatment  is  conducted 
and  from  which  its  results  are  ascertained.  The  study  of  final  results 
has  become  of  great  importance  in  orthopaedic  surgery,  and  on  this 
account  the  record  should  present  the  condition  of  the  patient  when 
treatment  is  begun,  in  a  form  that  may  be  readily  understood,  not 
only  by  its  writer  when  details  have  been  forgotten,  but  by  anyone 
who  may  in  after  years  consult  it.  To  this  history  notes  during  the 
course  of  the  disease  on  its  complications  and  incidents  and  on  the 
changes  in  the  treatment,  together  with  tracings  of  the  spine,  are  added 
at  regular  intervals  until  the  patient  is  cured. 

Treatment. 

The  general  treatment  of  tuberculous  disease  is  considered  in  Chap- 
ter V.  Pott's  disease  is  the  most  important  of  the  tuberculous  affec- 
tions of  the  bones,  and  the  importance  of  proper  surroundings,  proper 
food,  sunlight,  and,  within  certain  limits,  exercise  in  the  open  air,  can 
hardly  be  exaggerated. 

The  General  Principles  of  Mechanical  Treatment. — Under  normal  con- 
ditions the  weight  of  the  head  and   of  the  thoracic  and  abdominal 


TREATMENT.  59 

organs  tends  to  bend  the  spine  forward  and  downward,  a  tendency 
that  is  resisted  by  the  action  of  the  muscles  of  the  back.  If  the  re- 
sistance is  weakened,  as  in  Pott's  disease  by  the  direct  destruction  of 
the  weight-bearing  portion  of  the  spine,  this  tendency  toward  deformity 
is,  of  course,  greatly  increased.  Thus  the  pressure  and  strain  of  the 
superincumbent  weight  upon  the  weakened  part  that  the  upright  pos- 
ture entails,  are,  from  the  mechanical  standpoint,  the  most  important 
factors  in  the  production  of  deformity. 

When  the  body  is  bent  forward,  as  in  the  stooping  posture,  the  in- 
tervertebral discs  are  compressed  and  the  pressure  upon  the  vertebral 
bodies  is  increased  ;  so,  on  the  other  hand,  when  the  body  is  held  erect 
or  is  bent  backward,  this  pressure  is  lessened,  and  a  part  of  the  weight 
is  transferred  to  the  articular  processes  and  to  the  posterior  parts  of  the 
column.  In  fact,  specimens  show  that  the  continuity  of  the  spine 
may  be  preserved,  and  that  weight  may  be  supported  even  when  a 
vertebral  body  has  been  practically  destroyed. 

The  object  of  a  brace  or  other  support  used  in  the  treatment  of 
^  Pott's  disease  is  to  hold  the  spine  in  this  extended  position,  so  that 
pressure  on  the  diseased  vertebrae  may  be  removed.  One  aims  to  splint 
the  spine  as,  for  example,  one  would  splint  a  broken  back,  in  order  to 
relieve  the  symptoms  of  discomfort  and  pain,  so  depressing  to  the  patient, 
and  to  secure  the  rest  that  is  essential  to  repair. 

The  effectiveness  of  a  particular  splint  or  support,  when  applied  to 
a  broken  leg  or  to  a  diseased  spine,  depends  upon  the  area  that  it  covers 
on  either  side  of  the  part  to  be  supported  and  upon  the  accuracy  of 
its  adjustment,  as  well  as  upon  the  damage  that  the  part  has  already 
sustained,  and  the  strain  to  which  it  still  may  be  subjected. 

It  must  be  evident  that  the  body  because  of  its  size,  shape  and 
contents  is  not  suitable  for  the  accurate  adjustment  of  support,  and 
it  is  apparent  also  that  the  mechanical  conditions  are  more  unfavor- 
able in  some  parts  than  in  others.  For  example,  in  the  middle  of  the 
back  the  splint  is  likely  to  be  effective,  because  its  two  extremities,  at- 
tached to  the  pelvis  and  to  the  shoulders,  are  equidistant  from  the 
point  to  be  supported. 

These  conditions  are  reversed  in  disease  of  the  upper  thoracic  region, 
because  the  weight  of  the  head  and  of  the  arms  tends  to  increase  the 
deformity  and  because  of  the  insufficient  leverage  that  can  be  secured 
for  the  supporting  appliance.  The  pelvis  is  the  base  of  support  for  all 
forms  of  splints,  and  if  it  be  smaller  than  the  abdomen,  as  in  infancy, 
the  adjustment  of  efficient  support  is  very  difficult. 

Although,  in  actual  practice,  the  treatment  of  Pott's  disease  is  in- 
fluenced by  many  circumstances,  by  the  age  of  the  patient,  the  situa- 
tion of  the  disease,  the  duration  of  the  deformity  and  the  like,  yet  the 
relative  efficiency  of  braces  or  other  appliances  may  be  decided  on 
purely  mechanical  grounds.  Thus,  as  the  ultimate  deformity  of  Pott's 
•disease  is,  in  great  degree,  caused  by  the  force  of  gravity  acting  on  a 
weakened  spine,  the  most  effective  treatment  must  be  fixation  in  the 
horizontal  position,  since  only  by  this  means  can  the  strain  of  use,  and 


60  TUBERCULOUS  DISEASE  OF  THE  SPINE. 

the  pressure  of  the  superincumbent  weight  be  removed  completely ; 
and  relief  from  jars  and  injury,  that  favor  the  extension  of  the  disease, 
be  assured. 

Horizontal  Fixation. — Apparatus  for  this  treatment  must  be  quite 
independent  of  the  bed  on  which  it  may  be  placed,  and  of  such  ap- 
pliances several  forms  may  be  employed. 

The  reclinationgypsbettes  of  Lorenz  ^  is  simply  a  posterior  case  of 
plaster  of  Paris  enclosing  the  head  and  body. 

The  Phelps  bed  is  somewhat  similar.  A  thin  board  is  cut  in  the 
outline  of  the  child's  body  and  extended  legs.  It  is  padded  with 
cotton  wadding  and  covered  with  cotton  cloth  ;  the  patient  is  then 
placed  upon  it,  and  plaster  bandages  are  applied  to  enclose  the  body 
and  the  legs.  Later  the  front  is  cut  away,  so  that  the  patient  may  be 
removed  from  the  bed,  for  an  occasional  bath  and  change  of  clothing.^ 

The  wire  cuirasse  has  been  popularized  by  Sayre ;  ^  it  is  an  effec- 
tive appliance  although  somewhat  cumbersome  and  expensive. 

A  more  effective  and  more  convenient  form  of  support  is  the  Brad- 
ford frame  or  stretcher.  This  is  a  rectangular  frame  of  ordinary  gal-, 
vanized  gas  pipe,  or  better,  of  the  lighter  steel  tubing.  It  should  be 
a  few  inches  longer  and  slightly  wider  than  the  patient's  body.  Over 
the  frame,  a  cover  of  strong  canvas  is  drawn  tightly  by  means  of  cor- 
set lacings  or  straps  on  its  under  surface.  The  center  of  the  cover 
should  be  protected  by  a  strip  of  rubber  cloth,  as  will  be  found  to  be 

Fig.  27. 


Bradford's  bed-frame.     (Beadfokd  and  Lovett.) 

most  convenient  in  the  treatment  of  young  children,  who  wear  diapers  ; 
or  an  interval  may  be  left  for  the  use  of  the  bed  pan,  as  in  the  illustra- 
tion (Fig.  27)  ;  or  preferably  the  cover  may  be  made  in  three  parts,  of 
which  the  middle  section  may  be  removed  when  necessary,  so  that  the 
buttocks  may  not  sag  into  the  opening,  and  thus  make  the  support  for 
the  spine  less  efficient.  Several  sets  of  canvas  covers  may  be  provided, 
to  allow  for  frequent  washing ;  small  linen  draw  sheets  may  be  used 
to  protect  them,  and  a  folded  sheet  or  thin  hair  mattress  may  be  in- 
serted between  the  layers  of  the  canvas  cover,  if  the  straps  or  lacings 

'  Vide  Hoffa,  Lehrbuch  der  Orthopadisclien  Chir.,  p.  313. 

2  The  Phelps  plaster-of-Paris  bed,  Trans.  Am.  Ortho.  Ass'n,  Vol.  IV.,  1891,  p.  83. 

"  La  gouttiere  de  Bonnet.     K^dard,  Chir.  Orthopedique,  p.  243. 


TREATMENT. 


61 


cause  discomfort.  These  refinements  are,  however,  not  essential  in 
hospital  practice. 

As  has  been  stated,  the  position  of  over-extension  is  that  most  favor- 
able to  repair,  and  this  attitude  can  be  assured  by  bending  the  bars  up- 
ward from  time  to  time  as  the  deformity  recedes,  and  as  the  patient 
becomes  accustomed  to  the  apparatus.  The  spinous  processes  should 
be  protected  by  thick  pads  extending  on  either  side  of  the  spine  at 
the  seat  of  disease.  These  are  sewed  to  the  cover  and  when  properly 
adjusted  they  assure  better  support  and  fixation. 

The  method  of  attaching  the  patient  to  the  frame  varies  somewhat 
according  to  the  situation  and  character  of  the  disease.  In  ordinary 
cases  a  canvas  apron,  similar  to  that  used  with  the  back  brace  (Fig.  35), 
is  applied  and  is  buckled  to  the  sides  of  the  frame,  while  the  shoulders 
are  held  down  by  straps  crossing  the  chest,  or  by  axillary  straps  con- 
nected by  a  chest  band.  If  still  more  effective  fixation  is  desired,  as 
in  disease  of  the  upper  dorsal  region,  the  anterior  shoulder  brace,  as 

Fig.  28. 


The  modified  stretcher  splint,  showing  over-extension  of  the  spine,  with  traction  for  the  head  and 
limbs  as  applied  for  Pott's  paraplegia. 


used  with  the  back  brace  (Fig.  33),  may  be  attached  to  the  axillary 
straps.  In  disease  of  the  upper  and  middle  regions  of  the  spine  re- 
straint of  the  legs  is  not  necessary,  but  in  lumbar  disease  a  broad 
swathe  should  be  passed  across  the  thighs. 

In  disease  of  the  upper  region  of  the  spine  a  certain  amount  of 
traction  is  desirable  to  aid  in  the  reduction  of  deformity  and  to  pre- 
vent the  patient  from  raising  the  head.  This  traction  is  usually  ap- 
plied by  means  of  the  halter  as  used  with  the  jury  mast.  The  straps 
are  attached  to  a  crossbar  at  the  upper  extremity  of  the  frame  and 
traction  may  be  made  by  simply  tightening  them,  or  if  the  upper  part  of 
the  frame  is  somewhat  elevated  the  weight  of  the  patient's  body  makes 
the  proper  extension.  This  position  has  the  advantage,  also,  of  allow- 
ing the  patient  a  better  opportunity  to  see  what  is  going  on  about  him. 

In  disease  of  the  middle  cervical  region  traction  is  usually  of  ser- 
vice, and  fixation  of  the  head  is  always  indicated  in  addition  when  the 
occipito-axoid  region  is  involved,  either  by  sand  bags  on  either  side  or, 
preferably,  by  some  form  of  metal  brace. 


62  TUBERCULOUS  DISEASE  OF  THE  SPINE. 

In  the  treatment  by  horizontal  fixation,  the  child,  wearing  only  the 
underclothing,  is  attached  to  the  frame,  and  after  the  apparatus  has 
been  properly  adjusted,  he  is  never  allowed  to  sit  up  or  to  turn  the 
body  or  to  raise  the  head  until  this  form  of  treatment  has  been  discon- 
tinued. Children  quickly  accustom  themselves  to  a  restraint  that  so 
effectually  relieves  the  symptoms  of  weakness  and  pain. 

Once  a  day,  as  a  rule,  the  patient  is  removed  from  the  support  in 
the  following  manner  :  The  frame  is  placed  upon  a  bed  and,  the  straps 
having  been  loosened,  the  child  is  turned  from  the  frame  face  down- 
ward upon  the  bed  by  two  persons,  one  of  whom  supports  the  head 
and  shoulders  and  the  other  the  pelvis,  in  order  that  the  back  may  be 
held  rigid ;  the  shirt  which  opens  in  front  is  then  removed,  the  back 
is  rubbed  gently  with  alcohol  and  powdered ;  irritated  points  are  care- 
fully protected  and  bed  sores  are  prevented  by  padding  to  remove 
pressure.  Usually  no  trouble  whatever  is  to  be  anticipated  on  this 
score.  The  frame  bed  is  carefully  prepared,  the  draw  sheet  is  changed 
and  the  canvas  cover  is  tightened  if  necessary.  It  is  of  course  a  great 
convenience  to  have  two  frames  so  that  an  immediate  change  may  be 
made  from  one  to  the  other. 

Greater  fixation  of  the  spine  may  be  desirable  in  cases  of  more  acute 
disease.  This  may  be  attained  by  the  use  of  a  light  back  brace,  or  a 
plaster  jacket,  in  connection  with  the  frame.  Such  support  should 
not  be  applied  however  until  the  recession  of  deformity,  which  is 
to  be  expected  under  treatment  by  the  horizontal  fixation,  has  been 
obtained. 

As  has  been  stated  the  child  is  placed  upon  the  frame  wearing  noth- 
ing but  the  underclothing.  The  outer  garments  are  made  large 
enough  to  cover  both  the  body  and  the  frame  so  that  a  change  can  be 
made  without  disturbing  the  apparatus.  Thus  protected,  the  child 
may  pass  the  entire  day  in  the  open  air.  It  may  be  carried  in  the 
nurse's  arms  or  a  carriage  may  be  arranged  for  it.  In  colder  weather 
the  patient  may  be  enclosed  in  a  sleeping  bag  of  blanket  or  skin. 

Of  the  conditions  that  have  been  mentioned  as  favorable  to  the  cure 
of  tuberculous  disease,  but  one  is  lacking  in  the  treatment  by  horizontal 
fixation  ;  this  is  exercise.  Exercise  may  be  in  part  replaced  by  mas- 
sage of  the  arms  and  legs,  and  in  any  event,  beneficial  exercise  is  usu- 
ally out  of  the  question  during  the  phases  of  the  disease  for  which 
treatment  by  the  frame  is  indicated. 

Its  disadvantages,  when  properly  employed,  are  in  great  degree  imag- 
inary, while  its  positive  effects  in  checking  the  progress  of  deformity 
and  in  relieving  the  symptoms  of  the  disease  will  be  apparent  at  once. 
The  indications  for  treatment  by  this  method  will  be  considered  after 
the  description  of  the  other  forms  of  support. 

However  efficacious  the  horizontal  fixation  apparatus  may  be,  it  is 
incomplete  in  itself  since  it  must  be  supplemented  by  some  form  oi 
support  when  the  erect  posture  is  again  assumed.  Such  supports  are 
either  metallic  braces  applied  directly  to  the  spine  or  a  form  of  jacket 
that  surrounds  the  body ;  each  removes  a  part  of  the  superincumbent 


TREATMENT. 


63 


weight  from  the  seat  of  disease  by  holding  the  body  in  the  extended 
position  and  each  splints  the  weakened  spine  more  or  less  effectively. 
The  Back  Brace. — The  spinal  brace,  or  spinal  assistant,  as  the  orig- 
inal appliance  of  Dr.  C.  F.  Taylor  was  called,  consists  essentially  of 
two  steel  bars  that  are  applied  on  either  side  of  the  spinous  processes 
from  the  top  to  the  bottom  of  the  spine.  At  the  seat  of  disease  pads 
are  placed  to  provide  for  greater  pressure  and  fixation,  and  thus,  a 
fulcrum  over  which  the  spine  may  be  straightened  or  held  erect,  when 
the  two  extremities  of  the  brace 

are  firmly  attached  to  the  pelvis  Fig.  29. 

and  to  the  shoulders.  The 
attachment  at  the  lower  end  is 
made  by  means  of  a  pelvic  band 
of  sheet  steel  (gauge  18)  from 
one  and  a-half  to  two  inches  in 
width,  long  enough  to  reach 
from  one  iliac  spine  to  the 
other ;  it  is  placed  as  low  as 
possible  on  the  pelvis,  in  other 
words,  just  above  the  upper 
extremities  of  the  trochanters. 
To  this  the  uprights  are  firmly 
attached  at  an  interval  of  from 
one  and  a-quarter  to  one  and 
three-quarter  inches  from  one 
another,  so  that  the  spinous 
processes  may  pass  between 
them,  while  pressure  is  made 
on  the  lateral  masses  of  the  ver- 
tebrae. The  uprights  are  made 
of  varying  strength,  according 
to  the  age  of  the  patient,  usu- 
ally about  one-half  an  inch  in 
width  (of  gauge  8  to  12)  and 
of  such  quality  of  steel,  that 
although  unyielding  to  the 
strain  of  use,  it  may  be  readily 

•1,1  1  1     xi-   "^      The  Taylor  brace  and  head  support  applied  for  disease 

bent   by  wrenches,    and   thus  ^         of  the  upper  dorsal  region. 

accurately  adjusted  to  the  back. 

The  uprights  reach  to  the  root  of  the  neck,  or  to  about  the  level  of  the 
second  dorsal  vertebra ;  from  this  point  two  short  arms  of  metal  pro- 
ject forward  and  outward,  on  either  side  of  the  neck,  reaching  to  about 
the  middle  of  the  clavicles.  To  these,  padded  shoulder-straps  are  at- 
tached, which  pass  through  the  axillse  to  a  crossbar  on  the  back  brace]; 
thus  downward  pressure  on  the  shoulders  is  avoided  and  increased 
leverage  is  assured.     (Fig.  29.) 

Opposite  the  point  of  disease,  two  strips  of  thin  steel  about  three 
inches  in  length  are  fixed ;  these  are  slightly  wider  than  the  uprights 


64 


TUBERCULOUS  DISEASE  OF  THE  SPINE. 


and  are  perforated  for  the  attachment  of  the  pressure  pads.  They  may 
be  made  of  layers  of  canton  flannel  or  felt,  or  unyielding  material, 
such  as  leather  or  hard  rubber,  may  be  used  instead.  The  pads  should 
project  from  a  quarter  to  a  half  inch  in  front  of  the  uprights,  in  order 
that  firm  and  constant  pressure,  to  the  extent  that  the  skin  will  tolerate, 
may  be  made  at  the  seat  of  disease. 

In  measuring  for  this  brace  the  patient  is  placed  in  the  prone  posture 
and  a  tracing  of  the  outline  of  the  back  is  made  by  means  of  the  lead 

tape.  This  outline  may  be  cut  in  card- 
board and  fitted  to  the  back  ;  in  fact, 
if  the  mechanic  is  unfamiliar  with  the 
work,  each  part  of  the  brace,  uprights, 
pelvic  band,  etc.,  may  be  cut  in  card- 
board and  attached  to  one  another  to 
serve  as  a  model.  Before  the  brace  is 
finished  it  should  be  appliedj  to  the 
back  and  should  be  carefully  adjusted 
by  means  of  wrenches.  The  pelvic 
band  is  then  padded  and  the  parts 
that  come  in  direct  contact  with  the 
skin  are  usually  covered  with  leather. 

Fig.  31. 


The  Taj'lor  back  brace.     ( H.  L.  Taylor.  ) 


The  Taylor  chest  piece.    Two  triangular  pads  of  hard 
rubber  connected  by  a  bar. 


or,  in  the  treatment  of  young  children,  with  rubber  plaster  and  canton 
flannel  to  prevent  rusting. 

If  the  brace  is  applied  before  the  stage  of  deformity,  it  should  fol- 
low the  exact  shape  of  the  spine,  but  if  deformity  is  already  present, 
particularly  in  disease  of  the  thoracic  region,  it  should  be  made  some- 
what straighter,  in  order  to  permit  a  gradual  correction  of  the  com- 
pensatory lordosis  in  the  lumbar  region,  and  for  increased  leverage 
above  the  deformity.  As  has  been  stated,  a  certain  amount  of  reces- 
sion of  deformity  can  be  obtained  by  rest  in  the  horizontal  position, 
and  if  practicable  this  improved  contour  should  be  attained  before  the 
brace  is  applied.     The  apparatus  is  held  in  place  by  an  "  apron  " 


TREATMENT. 


65 


(Fig.  35)  which  covers  the  chest  and  abdomen,  to  which  straps  are 
attachec^.  Ordinarily  this  is  made  of  strong  linen  or  cotton  cloth,  but 
a  canvas  front  shaped  accurately  to  the  body  and  strengthened  with 
whale  bone,  is  a  much  more  comfortable  and  efficient  support.  In  ap- 
plying the  brace  the  pelvic  band  is  first  attached  to  the  apron,  then 
the  straps  in  order,  from  below  upward,  and  finally  the  shoulder  straps. 
Each  strap  is  tightened  until  the  brace  is  firmly  fixed  in  proper  posi- 
tion. When  a  brace  is  properly  applied  and  properly  fitted,  it  holds 
its  place  by  friction,  but  in  certain  cases,  when  the  disease  is  low  in 
the  back,  it  is  sometimes  of  advantage  to  apply  perineal  straps  to  hold 


Fig.  32. 


Fig.  33. 


Backward  traction  on  the   shoulders   fixes  the 
upper  dorsal  region. 


The  anterior  shoulder  brace  and  its  attachment. 


the  pelvic  band  firmly  in  its  place.  (Fig.  30.)  At  first,  the  brace  is 
removed  once  a  day  in  order  to  wash  and  powder  the  back,  the  same 
care  being  observed  in  moving  the  child  as  in  the  treatment  by  the 
frame,  but  when  the  back  has  become  accustomed  to  the  pressure,  the 
brace  should  be  removed  only  at  infrequent  intervals,  and  thus  if  de- 
sirable, only  under  the  supervision  of  the  surgeon. 

This  description  indicates  the  essential  qualities  of  the  back  brace. 
It  has  been  modified  in  various  ways ;  for  example.  Dr.  Taylor  long 
since  discarded  the  straight  pelvic  band  in  favor  of  one  of  a  \J  shape. 
(Fig.  30.)  This  makes  the  brace  somewhat  lighter  and  relieves  the 
sacrum  from  pressure,  but  it  does  not  add  to  its  effectiveness.  The 
efficiency  may  be  increased  however  by  improving  the  attachment  at 
5 


66 


TUBERCULOUS  DISEASE  OF  THE  SPINE. 


its  upper  extremity.  Taylor  has  done  this  by  placing  two  trian- 
gular pads  against  the  chest  as  shown  in  the  diagram.  (Fig.  31.) 
Schapps  uses  in  place  of  the  apron  an  anterior  frame  of  metal, 
counter  pressure  on  the  chest  being  provided  by  means  of  a  broad 
pad  of  perforated  sole  leather.  At  the  lower  part  a  band  of  metal 
crosses  the  body  and  pressure  is  made  directly  on  the  anterior  borders 
of  the  pelvic  bones. 

Each  method  is  an  improvement  on  the  simple  shoulder  straps  of  the 

Fig.  34. 


The  Taylor  back  brace  and  head  support  combined  with  the  "Whitman  anterior  support. 


original  brace,  but  neither  provides  the  quality  of  support  and  fixation 
that  is  required,  when  the  disease  is  of  the  upper  and  middle  segment 
of  the  thoracic  region.  In  such  cases  the  upper  part  of  the  chest  is 
flattened,  the  inclination  of  the  ribs  is  increased  and  the  shoulders  in- 
cline forward,  carrying  with  them  the  scapulae.  Thus  the  weight  and 
the  strain  of  the  motion  and  use  of  the  arms  tend  to  increase  the 
deformity. 

In  health,  direct  forward  or  reaching  movements  of  the  arms  are 
always  accompanied  by  an  increase  in  the  posterior  curvature  of  the 


TREATMENT. 


67 


dorsal  spine.  On  the  other  hand  if  the  shoulders  are  drawn  backward 
and  held  in  this  attitude,  the  curvature  of  the  spine  is  lessened  and 
the  chest  is  elevated  and  expanded.     (Fig.  32.) 

In  the  treatment  of  disease  of  the  upper  dorsal  region  it  should  be 
the  aim,  in  the  application  of  a  brace,  to  follow  this  indication  and  to 
apply  pressure  directly  upon  the  extremity  of  the  shoulders  to  assure 
the  greatest  possible  fixation  of  the  spine  and  to  restrain  the  move- 
ments of  the  arms,  that  tend  to  increase  the  deformity. 

The  accompanying  diagrams  (Fig.  33)  show  how  such  support  may  be 
applied.     Two  saucer-shaped  plates  of  hard  rubber  or  padded  metal 


Fig.  35. 


Fig.  36. 


The  anterior  shoulder  brace. 


The  scapular  pads. 


cover  the  heads  of  the  humeri  and  are  joined  by  a  rigid  bar  of  steel  which 
passes  across  but  does  not  touch  the  chest.  On  the  back  brace  are  placed 
two  triangular  pads  of  similar  construction  which  cover  and  press 
upon  the  scapulae.  These  pads  are  however  not  essential  and  are  often 
omitted.  The  back  brace  is  applied,  the  shoulders  are  then  drawn 
backwards  and  the  shoulder  cups  are  firmly  attached  by  straps  to  the 
neck  bars  of  the  brace  above  and  below  by  axillary  bands  in  the  usual 
manner.  By  this  means  the  thorax  is  elevated  and  the  spine  is  more 
effectively  fixed,  while  direct  movement  of  the  arms  forward  is  made 
impossible.  It  would  seem  that  such  restraint  would  be  irksome  to 
the  patient,  but  in  an  extended  use  of  the  apparatus  this  has  never 
been  complained  of.  In  many  instances,  even  when  the  disease  is  as 
low  as  the  tenth  dorsal  vertebra  it  may  be  used  with  advantage  but  it 


68 


TUBERCULOUS  DISEASE  OF  THE  SPINE. 


is  especially  indicated  when  the  disease  is  in  the  neighborhood  of  the 
seventh  dorsal  vertebra.  In  connection  with  the  shonlder  brace  it  is 
usually  advisable  to  apply  a  support  beneath  the  chin  to  prevent  the  for- 
ward inclination  of  the  neck  and  to  tilt  the  head  somewhat  backward. 
A  very  simple  and  inoflPensive  support  of  this  character  is  a  loop  of 
steel  surrounding  the  neck  and  attached  by  screws  to  a  back  bar  on  the 
brace.  (Fig.  37.)  If  a  more  efBcient  brace  is  required,  as  when  the 
disease  is  of  the  upper  dorsal  or  cervical  regions,  the  Taylor  head  sup- 
port should  be  used.  This  is 
an    oval    ring  of  steel  which 

may  be  clasped  about  the  neck  Ficx.  38. 

by  means  of  a  lateral  hinge. 
On  the  front  a  cup  of  hard 
rubber  supports  the  chin  and 
behind  the  ring  fits  upon  an 
upright  pivot,  that  may  be 
raised  or  lowered  upon  a  cross- 

Ftg.  37. 


The  loop  head  support. 


Disease  of  the  middle  cervical  regioB,  show- 
ing deformity  and  attitude.  This  patient  had 
been  paralyzed  for  one  year  before  treatment 
■was  begun.     (See  Fig.  39.) 


bar  on  the  upper  part  of  the  brace ;  free  lateral  motion  is  allowed  or 
it  may  be  checked  by  means  of  a  screw.     (Figs.  34  and  39.) 

If  absolute  fixation  of  the  head  is  indicated  as  in  disease  at  or  near 
the  occipito-axoid  region  two  steel  uprights  may  be  attached  to  the 
back  of  the  ring  and  are  bent  to  fit  the  posterior  and  lateral  aspect  of 
the  head  closely  and  a  band  of  webbing  is  passed  from  one  upright 
to  the  other  and  about  the  forehead. 


TREATMENT. 


69 


In  applying  the  support  the  chin  should  always  be  tilted  slightly 
upward 'in  order  to  throw  the  weight  of  the  head  backward.     (Fig.  39.) 

The  adjustment  of  the  head  support  is  made  easier  if  the  pivot  is 
attached  to  the  upright  by  means  of  a  ball  and  socket  joint  (Shaffer) 
(Fig.  29)  that  may  be  regulated  by  a  screw  and  key  ;  this  arrangement 
is  of  service  when  the  head  is  distorted  but  it  is  by  no  means  necessary. 


Fig.  39. 


FiCx.  40. 


The  Taylor  brace  and  head  support,  applied 
to  the  patient  shown  in  Fig.  38. 


The  Taylor  brace  with  jury  mast. 


When  the  Taylor  head  support  and  similar  appliances  are  used  the 
greater  part  of  the  pressure  is  sustained  by  the  chin  which  may,  after 
a  time,  undergo  an  unsightly  recession.  It  may  be  of  advantage  there- 
fore in  certain  cases,  particularly  when  restraint  of  the  motion  of  the 
neck  is  desirable  to  transfer  this  pressure  to  the  forehead  and  occiput 
by  extending  the  back  bars  upward  over  the  back  of  the  head  as  in 
Fig.  47. 


70  TUBERCULOUS  DISEASE  OF  THE  SPINE. 

A  jury  mast  may  be  used  to  support  the  head  also ;  its  adjustment 
will  be  described  in  connection  with  the  plaster  jacket  with  which  it  is 
usually  associated.     (Fig.  40.) 

The  Plaster  Jacket. — It  was  at  one  time  claimed  that  a  plaster  jacket 
applied  while  the  body  was  partially  suspended,  would  actually  relieve 
the  weakened  area  of  superincumbent  Aveight,  by  holding  the  dis- 
eased surfaces  apart.  This  is  not  the  fact.  The  jacket  supports  the 
spine  as  does  the  brace,  by  holding  it  in  the  erect  or  extended  position. 
One  is  a  circular  and  the  other  is  a  posterior  splint.  There  is  this 
difference  however,  the  brace  fits  the  spine  accurately  and  holds  its 
place  by  pressure  and  friction ;  the  jacket  is  held  in  place  by  the  sup- 
port of  the  projecting  pelvic  bones  ;  it  lacks  the  accuracy  of  adjustment 
of  the  brace  at  the  seat  of  disease,  but  on  the  other  hand  it  provides  a 
sohd  support  on  the  front  and  sides  of  the  body. 

Each  appliance  has  advantages  and  disadvantages  that  become  ap- 
parent in  the  treatment  of  certain  phases  of  the  disease  or  conditions 
of  the  patient. 

The  plaster  bandage  is  a  simple  support,  whose  efficiency  depends 
upon  the  accuracy  of  its  adjustment  to  the  irregularities  of  the  body, 
and  upon  the  leverage  that  it  exerts  above  and  below  the  point  of 
disease.  It  should  be  applied  while  the  body  is  held  in  the  best  pos- 
sible position  ;  its  inner  surface  should  be  smooth,  and  the  bony  promi- 
nences that  are  susceptible  to  friction  and  pressure  should  be  protected. 

A  seamless  shirt  should  be  worn ;  these  are  made  in  several  sizes 
and  are  sold  by  the  yard  at  a  low  price.  The  shirt  should  fit  the  body 
closely  and  should  be  long  enough  to  reach  to  the  knees.  The  patient 
is  then  placed  upon  a  stool,  and  the  halter  of  the  suspension  apparatus 
is  carefully  adjusted  ;  the  arms  are  extended  over  the  head  and  the 
hands  clasp  the  straps  or  rings  ;  thus  the  chest  is  expanded  to  its  full 
limit.  Sufficient  tension  is  made  upon  the  rope  to  partially  suspend 
the  body  and  to  draw  the  spine  into  the  best  possible  attitude  ;  in  most 
instances  the  heels  should  be  slightly  lifted  from  the  stool. 

Dr.  Sayre,  to  whom  we  are  indebted  for  the  exposition  of  this  valu- 
able means  of  treatment,  insists  that  the  sensations  of  the  patient  should 
be  the  guide,  and  that  traction  should  be  made  only  to  the  point  of 
comfort.  This  is  a  valuable  indication  in  the  treatment  of  the  adult, 
but  it  is  not  often  of  service  in  childhood. 

Before  applying  the  plaster  bandage,  pieces  of  piano  felting  or 
canton  flannel  of  sufficient  size  are  placed  about  the  anterior  pelvic 
spines,  over  the  upper  part  of  the  sternum  and  a  thin  strip  is  some- 
times used  to  cover  the  spinous  processes.  Finally  long  strips  of 
saddler's  felt,  or  of  other  material  of  sufficient  thickness,  are  applied 
on  either  side  of  the  prominent  spines  to  protect  them  from  friction 
and  to  provide  greater  pressure  and  fixation  at  the  seat  of  disease. 
The  "  dinner  pad  "  is  now  very  rarely  used,  except  in  the  treatment  of 
adults,  and  in  certain  cases  of  deformity,  in  which  the  abdomen  is 
retracted.  In  childhood  the  abdomen  is  usually  prominent,  and  as  the 
jacket  expands  somewhat  after  its  application   no  extra  space  is  re- 


TREATMENT.  71 

quired.  The  pad,  which  is  supposed  to  represent  the  space  necessary- 
after  a  -full  meal,  is  made  by  folding  a  small  towel  into  the  shape 
of  a  sandwich ;  this  is  attached  to  a  bandage  and  is  placed  beneath 
the  shirt  just  below  the  ensiform  cartilage ;  when  the  jacket  is  com- 
pleted it  may  be  drawn  out,  by  means  of  the  hanging  bandage,  leaving 
the  additional  space  for  emergencies. 

The  materials  for  the  jacket  should  be  of  the  best.  Fresh  dental 
plaster  should  be  rubbed  by  hand  into  strips  of  crinoline,  free  from 
glue.  The  bandages  should  be  from  three  to  five  inches  in  width,  and 
six  yards  in  length ;  from  three  to  six  being  required  for  a  jacket,  ac- 
cording to  the  size  of  the  child.  They  should  be  placed  on  end,  in  a 
pail  of  warm  water,  one  at  a  time  as  they  are  used.  No  salt  or  alum 
should  be  used  to  hasten  the  setting  of  the  plaster,  in  fact,  if  such  aid  is 
necessary,  it  is  unfit  for  use.  When  the  bubbles  have  ceased  to  rise, 
the  bandage  is  squeezed  gently  until  no  water  drips  from  it  and  the  loose 
threads  are  removed  from  the  ends. 

One  person  should  sit  behind  the  patient,  and  one  in  front,  while  a 
third  may  hold  the  rope  and  check  the  swaying  of  the  body.  The  one 
who  sits  behind  the  patient  may  clasp  the  child's  legs  between  his 
knees  and  thus  assure  better  fixation  of  the  pelvis.  The  pads  are  held 
in  position  until  they  are  fixed  by  the  plaster  bandages,  which  should 
be  applied  with  a  slight  and  even  tension. 

As  a  rule  the  jacket  should  be  of  uniform  thickness  throughout. 
This  thickness  need  not  exceed  one  eighth  to  one-fourth  of  an  inch 
and  it  may  be  even  lighter  in  certain  cases.  It  is  well  to  make  the 
first  turns  about  the  waist  and  to  use  the  first  bandage  about  the  pelvis 
since  the  pelvis  is  the  base  of  support ;  and  as  the  most  important 
point  for  counter  pressure  is  the  chest,  this  part  should  be  made  espe- 
cially strong. 

During  the  application  of  the  jacket  it  should  be  rubbed  constantly, 
in  order  that  the  different  layers  of  bandage  may  adhere  to  one  another, 
and  that  it  may  fit  the  projections  of  the  pelvis  and  body  closely. 
Meanwhile  the  attitude  of  the  patient  should  be  carefully  watched,  in 
order  to  prevent  lateral  inclination  of  the  body.  In  some  instances  it 
is  possible  to  lessen  the  deformity  in  the  dorsal  region,  by  the  exten- 
sion, and  by  backward  traction  on  the  shoulders,  while  the  jacket  is 
hardening. 

When  the  jacket  is  nearly  firm,  it  should  be  trimmed.  In  many 
instances  this  may  be  done  while  the  patient  is  in  the  swing,  but  if  he 
is  fatigued  he  may  be  placed  in  the  recumbent  posture. 

As  a  rule  the  front  of  the  jacket  should  reach  from  the  upper  mar- 
gin of  the  sternum  to  the  pubes ;  behind,  from  the  spines  of  the  scap- 
ulae to  the  gluteal  fold ;  laterally  it  should  be  cut  away  sufficiently  to 
prevent  chafing  of  the  arms  ;  and  on  either  side  of  the  pubes  an  oval 
section  is  cut  out,  to  allow  for  the  flexion  of  the  thighs  in  the  sitting 
posture.  Particular  attention  is  called  to  the  importance  of  making 
the  jacket  as  long  as  possible,  so  that  the  abdomen  may  be  contained 
■within  it,  instead  of  being  forced  out  beneath  its  lower  border.     (Fig. 


72 


TUBERCULOUS  DISEASE  OF  THE  SPINE. 


42.)  After  the  application  of  the  jacket,  the  patient  should  remain  in 
the  recumbent  posture  for  at  least  half  an  hour.  A  much  longer  period 
of  recumbency  is  always  advisable  as  it  does  not  become  absolutely  firm 
for  several  hours.  The  shirt  is  then  drawn  up  over  the  jacket  and  is 
sewed  to  the  neck  portion  ;  this  adds  much  to  neatness  and  cleanliness. 
The  shirt  must  be  drawn  tightly  about  the  neck,  in  order  to  guard 


Fig.  41. 


Fig.  42. 


The  plaster  jacket. 


The  plaster  jacket  suiiporting  the  abdomen. 


the  body  from  the  crumbs  or  other  objects  that  may  fall  beneath  the 
jacket,  and  in  many  instances  a  special  protector  in  the  form  of  a  wide 
collar  bib,  may  be  used  with  advantage.     (Fig.  41.) 

It  may  be  mentioned  in  this  connection  that  even  the  slightest  ex- 
coriation or  irritation  of  the  skin  beneath  tlie  jacket,  can  be  at  once 


TREATMENT. 


73 


detected  by  the  peculiar  odor.  Of  this  parents  should  be  informed, 
so  that  it  may  be  cut  down  and  the  source  of  the  irritation  removed 
at  once.     With  ordinary  care, 

"  sores,"  the  bugbear  of  the  Fi«-  43. 

plaster  jacket,  are  of  little  con- 
sequence. 

If  the  disease  is  of  the  mid- 
dle region  of  the  spine,  back 
ward  traction  on  the  shoulders 
is  indicated,  by  means  of  the 
anterior  shoulder  brace  de- 
scribed in  connection  with  the 
spinal  brace.     (Fig.  43.) 

In  many  instances  a  head 
support  is  required,  and  it  is 
of  course  always  indicated  in 
disease  of  the  upper  dorsal  and 
cervical  regions.  For  this  pur- 
pose the  jury  mast  is  most 
often  employed. 

The  jury  mast  should  be  of 
tempered  steel,  strong  enough 
to  hold  its  shape  under  the  ten- 
sion of  the  halter.  (Fig.  44.) 
Its  base  should  be  incorpo- 
rated firmly  in  the  jacket  below 
the  seat  of  disease ;  it  should 
be  long  enough  to  reach  well 
above  the  head  and  the  crossbar  should  be  placed  directly  over  the 
ears.     (Fig.  45.) 

Fig.  44. 


The  jury  mast  and  the  anterior  support. 


Jury  mast. 


The  halter  should  be  applied  with  as  much  tension  as  can  be  borne 
comfortably  by  the  patient,  so  that  the  weight  of  the  head  may  be  at 


74  TUBERCULOUS  DISEASE  OF  THE  SPINE. 

least  partly  supported  and  the  chin  should  be  tilted  slightly  upward, 
the  aim  being  to  draw  the  head  backward  and  thus  to  extend  the  spine. 
In  disease  of  the  cervical  region  the  crossbar  should  be  fixed  to  check 
lateral  motion  of  the  head,  but  this  is  unnecessary  when  the  disease 
is  at  a  lower  level. 

The  Application  of  the  Jacket  in  the  Recumbent  Posture. — The  jacket 
may  be  applied  while  the  patient  lies  extended  in  the  prone  posture, 
by  the  hammoeh  method  suggested  by  Davy  of  London. 

Fig.  45. 


The  jacket  and  jury-mast  applied.    The  same  patient  is  shown  in  Fig.  28. 

A  long  narrow  strip  of  cotton  cloth  is  passed  under  the  shirt  and 
the  two  extremities  are  drawn  tight  enough,  by  means  of  a  pulley,  to 
support  the  child  in  the  proper  attitude.  An  opening  is  cut  for  the 
face  and,  if  advisable,  traction  may  be  made  on  the  arms  and  legs  of 
the  patient.  The  bandages  are  then  applied  in  the  ordinary  manner 
after  which  the  cloth  may  be  cut  short  at  one  end  and  removed. 

This  procedure  is  of  service  in  the  treatment  of  weak  or  paralyzed 
patients,  but  the  adjustment  is  somewhat  less  accurate  than  by  the 
ordinary  method.  The  jacket  may  be  applied  in  the  supine  posture 
by  means  of  the  GoldtJnvalt  support.  This  latter  method  may  be  em- 
ployed with  advantage  in  the  routine  application  of  the  plaster  jacket. 
(Fig.  46.) 


TREATMENT. 


75 


The  Application  of  the  Jacket  to  Patients  who  have  been  Treated  on 
the  Stretcher  Frame. — A  very  satisfactory  method  of  applying  a  plaster 
jacket  in  young  subjects^  whose  deformity  has  been  corrected  in  whole 
or  part  by  recumbency  on  the  frame  in  the  over-extended  position,  is 
the  following.  The  patient  is  suspended  face  downward  in  the  hori- 
-zontal  position  by  two  assistants,  one  holding  the  arms  and  the  other 
the  thighs ;  thus  a  certain  amount  of  traction  is  exerted  while  the 
weight  of  the  body  tends  to  over-extend  the  spine. 

In  this  attitude  a  jacket  is  quickly  applied,  and  the  child  is  at 
once  replaced  upon  his  frame  which  has  been  protected  by  a  rubber 

Fig.  46. 


The  routine  method  of  applying  the  plaster  jacket  in  the  horizontal  position  by  means  of  the 
Ooldthwait  appliance.  The  essential  part  of  the  apparatus  is  shown  in  duplicate  in  the  foreground 
(A).  Upon  its  upper  extremities  two  thin  bands  of  steel,  similar  to  those  used  in  the  Taylor  brace, 
are  placed  (B),  to  support  the  pads  which  protect  the  spinous  processes  at  the  deformity.  The  child  is 
placed  upon  the  support,  as  illustrated  in  the  figure,  and  the  plaster  bandages  are  carried  about  the 
body  on  either  side  of  the  support,  including  the  pads.  When  the  jacket  is  Arm  the  patient  is  lifted 
from  the  support.  By  this  method  a  certain  amount  of  leverage  is  exerted  upon  the  deformity,  but 
less  than  when  the  other  forms  of  the  appliance  are  used.    See  Figs.  58,  59  and  60. 

sheet.  Thus  the  plaster  jacket,  during  the  hardening  process,  must 
conform  to  the  habitual  posture  of  recumbency.  In  addition,  the 
pressure  pads  of  the  frame  indent  the  bandage  on  either  side  of  the 
spinous  processes  (Fig.  48)  and  thus  assure  better  support  and  fixa- 
tion. This  is  a  very  effective  method  of  applying  the  jacket  in  this 
class  of  cases,  because  it  is  not  necessary  to  retain  the  child  in  an  un- 
comfortable position  while  the  bandage  is  hardening,  and  because  ac- 
curacy of  adjustment  in  the  best  possible  attitude  is  assured. 

As  a  rule  a  jacket  may  be  worn  for  two  months,  although  not  infre- 
quently in  hospital  practice  it  may  remain  for  six  months,  or  even 


76 


TUBERCULOUS  DISEASE  OF  THE  SPINE. 


longer,  and  yet  be  fairly  efficient.  Usually  one  jacket  is  removed  and 
another  applied  on  the  same  day,  but  if  the  skin  is  at  all  sensitive  it 
is  well,  after  the  washing  and  powdering,  to  re-apply  the  old  jacket, 
closing  it  with  adhesive  plaster,  and  allow  an  interval  of  a  few  days 
before  applying  the  permanent  one. 

The  Plaster  Corset. — In  the  stage  of  recovery  the  jacket  may  be  re- 
placed by  a  corset.  A  jacket,  made  and  trimmed  as  already  described, 
is  cut  down  the  center  and  removed  from  the  body.     It  is  carefully 

Fig.  47. 


Fig.  48. 


A  fixation  support  for  the  head.     This  may  be 
used  with  tlie  brace  or  with  the  jacket. 


Jacket  applied  by  the  stretcher  method,  showing 
the  depressions  in  the  jacket  caused  by  the  frame 
pads. 


readjusted  to  its  former  shape,  bandaged  with  the  cut  surfaces  in  close 
apposition,  and  is  thoroughly  dried  or  baked.  All  wrinkles  are  then 
cut  away  from  the  inner  surface,  and  extra  padding  is  applied  if  neces- 
sary ;  the  shirt  is  drawn  tightly  about  the  borders  of  the  jacket  and 
strips  of  leather  provided  with  hooks  are  sewed  in  front  so  that  it  may 
be  laced  like  an  ordinary  corset.  It  may  be  removed,  from  time  to 
time,  to  allow  for  bathing,  but  it  should  always  be  removed  and  re- 
applied while  the  patient  is  suspended  or  in  the  recumbent  position. 
Corsets  are  often  used  in  place  of  the  jackets  in  the  treatment  of  the 


TREATMENT.  77 

active  stage  of  the  disease,  but  they  are  less  effective,  since  the  repeated 
stretching  during  their  removal  and  reapplication  weakens  them  and 
impairs  the  accuracy  of  adjustment ;  and,  in  addition,  one  of  the  strong- 
est arguments  in  favor  of  the  use  of  plaster  of  Paris,  that  treatment  is 
under  the  control  of  the  surgeon,  is  nullified. 

Comparison  of  the  Two  Forms  of  Ambulatory  Support. — The  most  se- 
vere criticisms  of  the  jacket  have  been  made  by  those  unfamiliar  with 
its  use,  on  theoretical  grounds  rather  than  from  actual  observation. 
While  it  is  admitted  that  there  are  certain  objections  to  its  use,  yet 
experience  shows  that  when  it  is  applied  in  a  proper  manner  under 
proper  conditions  it  is  a  thoroughly  reliable,  efficient  and  often  indis- 
pensable means  of  treatment.  Indeed,  it  may  be  stated  that  by  means 
of  the  jacket  and  the  Bradford  frame  it  is  possible  to  treat  nearly  every 
case  of  Pott's  disease  without  the  aid  of  the  professional  bracemaker, 
and  with  success. 

It  is  evident,  however,  that  under  certain  conditions  the  jacket  must 
be  inferior  to  the  brace,  in  early  childhood,  for  example,  when  the 
pelvis  is  not  sufficiently  developed  for  proper  support.  Again  when 
the  disease  is  low  down,  at  or  near  the  lumbo-sacral  junction,  the 
lower  border  of  the  jacket  does  not  hold  the  pelvis  with  sufficient 
security  to  provide  the  proper  fixation.  In  the  upper  dorsal  region 
the  attachments  for  accurate  fixation  may  be  more  readily  applied  to 
the  brace,  and  in  disease  of  the  cervical  region  the  metallic  head 
support  is  to  be  preferred  to  the  jury  mast,  for  the  reason  that  it 
cannot  be  removed  by  the  patient  as  can  be  the  straps  of  the  halter. 
The  traction  of  the  jury  mast  is  very  effective  when  properly  used  and 
particularly  so,  when  painful  distortion  of  the  head  is  present,  but  the 
tension  on  the  straps  is  rarely  constant  and  thus  it  loses  in  effective- 
ness. A  rigid  support  is,  of  course,  essential  in  disease  of  the  atlo- 
axoid  region. 

The  jacket  will  be  found  to  be  most  efficient  in  disease  of  the  spine 
from  the  tenth  dorsal  to  the  second  lumbar  vertebra.  It  is  not  only 
effective  but  it  is  often  a  more  comfortable  support  than  the  spinal 
brace.  It  is  also  more  efficient  than  the  brace  when  lateral  deviation 
of  the  spine  is  present ;  and  from  the  clinical  standpoint,  it  is  often 
more  efficient  in  relieving  the  symptoms  of  pain  in  this  region,  when 
the  disease  is  at  all  acute. 

One  may  conclude,  then,  that  each  form  of  support  may  be  used  ac- 
cording to  the  indications.  The  absolute  control  of  the  treatment, 
assured  by  the  use  of  the  plaster  jacket  will  often  over-balance  the 
claims  of  the  brace ;  in  practice  among  the  poor,  when  choice  of  means 
is  not  always  permitted,  it  is  indispensable ;  and  it  may  be  used  with 
fair  success,  even  under  conditions  that  theoretically  contraindicate  its 
employment. 

Modifications  of  the  Jacket. — Occasionally,  the  form  of  the  jacket  may 
be  changed  to  meet  special  indications  ;  for  example,  backward  traction 
may  be  secured  by  carrying  the  bandages  over  the  shoulders  ;  or  the 
head  may  be  fixed  in  the  support,  if  the  jury  mast  is  not  at  hand  (Fig. 


78 


TUBERCULOUS  DISEASE  OF  THE  SPINE. 


49) ;  or  one  or  both  thighs  may  be  included  in  a  spica  jacket  in  painful 
disease  of  the  lower  region,  when  psoas  spasm  is  a  symptom.  Such 
modifications  are  required  rather  for  temporary  emergencies  than  for 
continuous  treatment. 

Dr.  H.  L.  Taylor  has  recommended  what  he  calls  the  bivalve  plas- 
tic splint  of  plaster  of  Paris. 

"  A  paper  pattern  of  the  posterior  valve  is  made  from  the  patient's 
back  allowing  one  inch  extra  around  the  edge  to  be  folded  back. 
From  this  pattern  eight  or  ten  thicknesses  of  crinoline  are  cut  of  the 
same  size  and  shape.     The  patient  bemg  supported  face  downward  on 

a  rest  under  the  pelvis  and 
Pj(j   49  another  under  the  upper  part 

of  the  sternum,  the  crinoline 
sheets  are  dipped  into  plaster 
cream  in  a  large  flat  pan, 
applied  to  the  back,  the  felt 
pads  being  in  position  ;  the 
edges  are  folded  back  for 
greater  rigidity  and  the  whole 
carefully  moulded  to  the  pa- 
tient and  allowed  to  set,  after 
which  the  patient  is  turned 
on  his  back  and  the  anterior 
valve  made  in  a  similar 
manner. 

"  The  jacket  should  be 
made  firm  and  rigid,  especi- 
ally at  the  edges,  and  should 
reach  in  front  from  the  pubes 
to  the  top  of  the  sternum. 
Such  an  apparatus  is  rigid, 
removable  and  adjustable  and 
brings  the  pressure  to  bear  on 
definite  areas  selected  with 
regard  to  its  mechanical  ac- 
tion. The  splint  may  be  re- 
moved to  cleanse  the  back  or 
to  note  its  efficiency,  taking 
the  impressions  made  by  the 
felt  pads  either  side  the 
spinous  processes  as  a  guide. 
If  more  leverage  is  needed,  the  felting  may  be  reinforced  or  the  depth 
of  casing  reduced  by  paring  the  lateral  edges.  In  other  words  the 
jacket  has  ceased  to  be  mainly  a  casing  and  has  become  a  mechanism 
under  the  surgeon's  control  and  capable  of  being  manipulated  to  pro- 
duce definite  mechanical  results." 

Corsets  of  Other  Material  than  Plaster  of  Paris. — Corsets  of  wood, 
leather,  paper,  poro-plastic  felt  or  celluloid  are  sometimes  used.    These 


Plaster  bandage  iucluding  the  lu-ad  to  hold  the 
spine  in  the  extended  position  after  the  correction  of 
deformity. 


TREATMENT. 


79 


are  constructed  on  a  plaster  cast  of  the  body,  a  thin  accurately  fitting 
jacket  being  used  as  a  mould. 

Such  corsets  have  certain  advantages  of  durability  and  elegance, 
but  none  of  them  has  the  accuracy  of  fit  of  the  plaster  of  Paris  corset, 
which  is  moulded  directly  on  the  body  by  constant  manipulation  during 
the  stage  of  solidification.  Corsets  of  this  class  are  usually  somewhat 
expensive,  and  on  that  account  are  often  worn  after  they  are  outgrown 
or  no  longer  fit  the  patient.  Their  use  is  practically  limited  to  the 
stage  of  recovery  or  for  other  affections  than  Pott's  disease. 

Fig.  50. 


The  Thomas  collar.     (Eidlon  and  Jones.) 

Of  these  corsets,  one  of  the  best  is  that  used  by  Weigel,  of  Roches- 
ter, made  of  alternate  layers  of  linen  cloth  and  wood  pulp  matrix  paper, 
fixed  by  a  mixture  of  paste  and  glue. 

A  more  durable  corset  may  be  constructed  of  aluminum,  as  advocated 
by  Phelps.  This  may  be  obtained  in  thin  sheets,  which  may  be  ham- 
mered upon  the  plaster  cast  into  the  proper  shape.  The  two  halves 
are  attached  by  hinges  in  the  back  and  are  perforated  to  allow  for 
ventilation. 

In  the  final  stage  of  treatment,  the  Knight  brace,  a  light  steel  frame 
with  corset  front  may  be  employed  (Fig.  132),  or  a  long  corset  similar 


Fig.  51. 


The  Thomas  collar.  A  piece  of  thin  sheet  metal  is  cut  wide  enough  to  reach  from  the  sternum 
to  the  chin  and  from  the  back  of  the  neck  to  the  base  of  the  occiput.  The  edges  are  turned  out 
and  the  whole  properly  covered  with  felt  and  fitted.     (Eidlon  and  Jones.  ) 

to  that  ordinarily  worn  by  women,  but  strengthened  by  the  insertion 
of  light  steel  bars  along  the  spine,  is  often  sufficient. 

Other  Forms  of  Support. — In  certain  cases  of  disease  of  the  lower 
lumbar  region  of  the  spine,  it  may  seem  advisable  to  restrain  the 
movements  of  the  thighs,  although  ordinarily,  when  this  is  necessary 
the  patient  should  be  placed  upon  the  frame.     Such  restraint  may  be 


80 


TUBERCULOUS  DISEASE  OF  THE  SPINE. 


Fio.  52. 


attained  by  making  the  back  bars  of  the  brace  stronger  and  extending 
them  down  the  back  of  the  thighs  to  the  knees  like  a  double  Thomas 
hip  brace. 

If  the  jacket  is  used,  it  may  be  extended  to  a  single  or  double  spica 
for  the  same  purpose,  as  has  been  mentioned.  Such  appliances  are  use- 
ful when  psoas  spasm  and  "  cramp  "  are  troublesome  symptoms. 

In  disease  of  the  cervical  region  a  certain  amount  of  support  and 
fixation  may  be  obtained  by  collars  of  poro-plastic  felt,  plaster  of  Paris 
or  other  material.  The  Thomas  collar  is  the  best  of  this  type  of  sup- 
port, but  none  of  them  is  thoroughly  efficient  unless  used  with  a 
brace  to  control  the  larger  movements  of  the  spine.  They  are  use- 
ful in  emergencies  but  they  are 
not  often  required  when  proper 
braces  can  be  obtained. 

Many  other  forms  of  appa- 
ratus of  greater  or  less  merit 
might  be  described,  but  space 
has  only  permitted  a  detailed 
account  of  three  forms  that,  it 
would  seem,  best  represent  the 
essential  principles  involved  in 
the  treatment  of  Pott's  disease. 
The  Principles  of  Treat- 
ment in  Their  Practical  Ap- 
plication.— After  the  descrip- 
tion of  the  special  forms  of 
appliances  used  in  the  routine 
treatment  of  Pott's  disease,  one 
may  consider  with  advantage 
the  treatment  in  its  more  direct 
relation  to  the  patient.  The 
object  of  this  treatment  is  to 
relieve  the  symptoms,  to  main- 
tain and  to  improve  the  vital 
resistance  of  the  patient,  to 
check,  to  remedy  and  to  prevent  deformity.  Under  favorable  con- 
ditions the  death  rate  is  small,  and  pain  is  easily  relieved,  but  preven- 
tion of  deformity  is  often  extremely  difficult. 

The  effect  of  treatment  must  be  estimated  not  simply  by  its  relief 
of  the  symptoms  of  the  disease,  since  deformity  may  steadily  advance 
in  spite  of  the  apparent  well-being  of  the  patient,  but  it  must  be  se- 
lected and  continued  or  changed  with  the  aim  of  combating  ultimate 
deformity,  and  on  this  standard  success  or  failure  must  be  determined. 
It  is  probable  that  noticeable  deformity  might  be  prevented,  nearly 
always,  if  treatment  were  applied  in  season.  But  practically  such 
opportunity  is  not  often  offered,  and  the  local  deformity  that  represents 
destruction  of  bone,  may  be  considered  as  irremediable.  There  is  also 
a  dwarfing  and  blighting  effect  of  the  disease,  which,  although  it  is 


The  Thomas  collar  applied.    (Eidlon  and  Jones.  ) 


PRINCIPLES  OF  TREATMENT  IN  PRACTICAL  APPLICATION.     81 


Fig.  53. 


usually  associated  with  marked  deformity,  is  always  to  be  feared,  par- 
ticularly when  the  disease  affects  the  middle  or  lower  region  of  the 
spine  in  early  childhood,  and  is  severe  and  prolonged  in  its  course. 
By  proper  treatment  one  may  hope  to  check  the  progress  of  the  dis- 
ease and  even  to  remedy  the  deformity  in  great  degree,  by  freeing  the 
spine  from  the  deforming  influence  of  local  disease,  and  by  preventing 
or  removing  the  symptomatic  distortions 
such  as  psoas  contraction  or  wry  neck. 

Indications  for  Treatment  "by  Recumbency. 
— As  has  been  stated  already,  the  most 
important  influence  toward  deformity  when 
the  spine  has  been  weakened  by  disease,  is 
the  force  of  gravity ;  therefore  horizontal 
fixation  is  the  most  efficient  means  of  pre- 
venting deformity,  and  it  assures  the  rest 
for  the  diseased  spine  that  favors  repair. 

This  is  then  the  treatment  of  last  resort, 
the  treatment  for  emergencies  and  in  many 
instances  the  treatment  of  choice  and  rou- 
tine. It  is  indicated  as  the  routine  treat- 
ment in  infancy,  and  in  early  childhood  up 
to  the  age  of  three  years,  at  least  during  the 
acute  and  progressive  stage  of  the  disease, 
because  the  structure  of  the  spine  offers  but 
little  resistance  to  the  extension  of  the  des- 
tructive process,  and  because  prolonged  di- 
sease and  deformity  are  much  more  dis- 
astrous at  this  age  of  rapid  growth  than  at 
a  later  period. 

The  time  that  this  treatment  should  be 
continued  is  determined  by  the  character  of 
the  disease,  by  the  presence  or  absence  of 
complications  and  above  all  by  the  condition 
of  the  patient.  A  year  would  perhaps  repre- 
sent the  average  time  that  horizontal  fixa- 
tion may  be  employed  with  advantage  in 
appropriate  cases.  When  the  frame  is  used 
in  the  manner  described,  and  when  the  child      Finai  result  of  luinbar  disease;  spon- 

.-,  ii'iii  •,!         taneous    absorptioQ  of  abscess,    and 

IS  taken  regularly  into  the  open  air,  the   but  slight  deformity,  see  Fig.  is. 
general  condition  almost  always  improves 

with  the  complete  relief  of  the  pain,  weakness  and  discomfort  that  the 
treatment  assures. 

If  the  progress  of  the  local  disease  is  toward  repair,  the  patient 
becomes  restless,  he  no  longer  lies  motionless  when  he  is  removed 
from  the  frame,  but  turns  and  twists  the  body  in  a  manner  that 
shows  the  absence  of  muscular  spasm.  At  this  time  it  is  well  to 
fit  the  back  brace  that  is  to  be  used  when  the  frame  is  discarded, 
provided  it  has  not  already  been  used  in  conjunction  with  the  hori- 
6 


82 


TUBERCULOUS  DISEASE  OF  THE  SPINE. 


zontal  fixation  ;  then  little  by  little  the  upright  posture  and  ambulation 

are  resumed. 

Fig.  54. 


Pott's  disease  of  the  middle  dorsal  region,  a  type  of  disease  in  whicL  horizontal  fixation  is  always 
indicated.    H.  S.,  age  14  months. 

In  many  instances  absolute  recumbency  may  not  be  required,  but 
the  period  of  activity  must  be  carefully  regulated,  and  must  be  discon- 

FiG.  55. 


H.  S.  after  14  months  of  fixation  on  the  modified  Bradford  frame,  shows  the  recession  of  deformity, 

Compare  with  Fig.  54. 


SPECIAL  INDICATIONS  FOR   TREATMENT.  83 

tinned  when  there  is  evidence  of  discomfort  or  weakness  or  pain.  If 
the  peri6d  of  activity  must  be  short,  it  should  be  passed  in  the  open 
air.  The  passive  attitude  of  sitting,  although  less  strain  is  thrown 
upon  the  spine  than  during  activity,  may  be  even  worse  for  the  pa- 
tient ;  thus  the  reclining  or  semi-reclining  posture  should  be  assumed, 
as  a  rule,  when  the  child  is  in  the  house,  at  least  during  the  active 
stage  of  the  disease.  Even  if  the  patient  appears  to  be  perfectly  sup- 
ported, the  time  spent  in  bed  should  be  long,  and  a  period  of  rest  in 
the  middle  of  the  day  should  be  enforced. 

The  arguments  in  favor  of  horizontal  fixation  in  early  childhood  do 
not  apply  to  disease  in  the  adult.  At  this  age  the  structure  of  the 
spine  is  resistant,  and  deformity  is  little  to  be  feared,  while  such  con- 
finement would  be  irksome  and  impracticable  ;  thus  local  support, 
supervision  and,  if  possible,  a  change  of  climate,  must  be  the  treat- 
ment of  selection  for  the  adolescent  or  adult. 

In  the  middle  period,  from  the  third  to  the  tenth  year  horizontal 
fixation  is  the  treatment  for  emergencies ;  for  paralysis,  for  abscess, 
for  dangerous  disease  of  the  atlo-axoid  region,  for  progressive  deformity, 
and  for  pain  that  cannot  be  relieved  by  the  ordinary  means. 

Special  Indications  for  Treatment  of  Disease  of  the  Different 
Regions  of  the  Spine. 

In  the  selection  of  treatment,  and  in  the  general  management  of 
Pott's  disease  each  region  of  the  spine  must  be  judged  by  itself,  since 
in  each  there  are  special  difficulties  to  be  met,  and  complications  to  be 
feared,  that  may  influence  the  prognosis  and  lead  to  modifications  of 
the  routine  of  treatment. 

The  Lower  Region. — The  prognosis  is  good  in  disease  of  the  lower 
region,  the  symptomatic  attitude  is  favorable,  the  part  may  be  easily 
supported,  the  cases  are  often  seen  before  the  deformity  is  at  all  ex- 
treme, and  one  may,  as  a  rule,  predict  recovery  without  noticeable  de- 
formity or  at  most  a  slight  shortening  and  broadening  of  the  body  and 
a  peculiar  erectness  of  attitude. 

Uncomplicated  cases  may  be  treated  with  the  brace  or  jacket.  The 
brace  is  the  better  support  when  the  disease  is  near  the  sacrum, 
while  the  jacket  is  often  more  comfortable  and  more  effective  than 
the  brace  when  the  middle  and  upper  lumbar  region  is  diseased,  par- 
ticularly when  lateral  deviation  of  the  spine  is  present.  When- 
ever the  tendency  to  psoas  contraction  is, at  all  marked  or  when  pain 
or  cramps  in  the  legs  are  complained  of,  the  period  of  activity  should 
be  carefully  restricted ;  in  fact  the  "  night  cry  "  is  an  indication  for  a 
day  of  rest  in  bed. 

The  most  troublesome  complications  of  this  region  are  psoas  con- 
traction aud  the  abscess  with  which  it  is  often  combined. 

As  has  been  stated,  psoas  contraction  changes  the  attitude  of  over- 
erectness,  favorable  to  repair,  to  a  forward  stoop  that  increases  the 
pressure  and  friction  at  the  seat  of  disease.     If  this  attitude  persists 


84  TUBERCULOUS  DISEASE  OF  THE  SPINE. 

and  if  it  becomes  fixed  by  permanent  changes  such  as  are  likely  to 
follow  the  burrowing  of  a  pelvic  abscess,  the  result  is  one  of  most 
disastrous  deformity,  the  body  and  the  legs  are  approximated  and  the 
erect  attitude  is  made  impossible.  In  neglected  cases  of  this  char- 
acter, tenotomy  and  forcible  correction  or  even  subtrochanteric  osteot- 
omy may  be  necessary  to  overcome  the  secondary  deformity. 

In  ordinary  cases  of  psoas  contraction,  and  when  one  leg  only  is 
flexed,  the  patient  may  be  allowed  to  go  about  using  a  high  shoe  on 
the  unaffected  side  and  crutches,  so  that  the  flexed  leg  need  not  affect 
the  attitude.  If,  however,  the  contraction  persists,  it  is  well  to  place 
the  patient  on  the  frame,  and  to  reduce  the  flexion  by  traction  in  the 
line  of  deformity,  as  will  be  described  in  the  treatment  of  disease  of 
the  hip  joint.  Persistent  psoas  contraction  is  almost  always  a  symptom 
of  abscess  about  the  origin  or  in  the  substance  of  the  muscle,  and  when 
it  is  accompanied  by  pain,  it  is  always  an  evidence  of  active  disease. 

Abscess  may  be  expected  as  a  complication  in  at  least  50  per  cent, 
of  the  cases  of  disease  of  this  region,  but  it  is  by  no  means  always 
accompanied  by  psoas  contraction,  any  more  than  psoas  contraction  is 
always  caused  by  abscess.  Abscess  unaccompanied  by  contraction 
more  often  has  its  origin  above  the  lumbar  region,  so  that  in  its  descent 
it  passes  along  the  surface  but  does  not  involve  the  substance  of  the 
muscle. 

Attention  is  especially  called  to  the  fact  that  the  bad  results  of  Pott's 
disease  of  this  region  are  almost  invariably  caused  by  allowing  flexion 
of  the  legs,  whether  it  be  symptomatic  of  abscess  or  not,  to  persist, 
therefore  the  importance  of  preventing  and  correcting  this  deformity 
cannot  be  over-estimated.  It  should  be  stated,  however,  that  in  dis- 
pensary practice,  w^hen  special  care  cannot  be  provided,  one  often  sees 
psoas  contraction  that  may  have  persisted  for  months  relax,  if  the 
progress  of  the  disease  is  favorable,  without  treatment  other  than  the 
routine  fixation  of  the  spine  by  the  brace  or  jacket.  In  certain  cases, 
one  or  both  thighs  may  be  fixed  by  the  plaster  bandage  or  by  the  back 
bars  attached  to  the  brace,  when  pain  and  spasm  are  troublesome,  but 
as  a  rule  rest  on  the  back  until  the  acute  phase  of  the  disease  has 
passed  is  to  be  preferred. 

The  Lower  Dorsal  Region. — Disease  of  the  lower  dorsal  region,  the 
middle  of  the  back,  is  very  favorably  situated  for  effective  mechanical 
treatment,  and  psoas  contraction  and  abscess  are  much  less  troublesome 
than  in  the  lower  part  of  the  spine.  The  brace  or  the  jacket  is  an 
efficient  support,  and  the  symptoms  are,  as  a  rule,  easily  relieved. 

Deformity  sometimes  increases,  almost  imperceptibly,  by  a  progres- 
sive forward  bending  or  lordosis  of  the  flexible  lumbar  spine  below 
the  projection.  One  must  guard  against  this  by  applying  the  jacket 
firmly  while  the  spine  is  made  as  straight  as  possible,  or  if  the  brace 
is  used,  the  lumbar  spine  should  be  drawn  firmly  against  it. 

If  lateral  inclination  of  the  body  is  so  marked  as  to  interfere  with 
the  proper  application  of  a  brace,  preliminary  rest  in  bed  is  indicated. 
Lateral  deviation  can  be  corrected  as  a  rule  by  the  jacket  without  re- 


SPECIAL  INDICATIONS  FOB  TREATMENT.  85 

cumbency,  although  this,  as  other  forms  of  symptomatic  distortion, 
should  be  treated  ordinarily,  if  not  by  complete  rest,  at  least  by  care- 
ful regulation  of  the  period  of  activity. 

Disease  of  the  Middle  and  Upper  Dorsal  Region. — This  is,  from 
the  standpoint  of  prevention  of  deformity,  the  most  difficult  region  of 
the  spine  to  treat,  although  the  symptoms  of  the  disease  may  be  easily 
relieved. 

Deformity  is  present  in  nearly  all  cases  when  treatment  is  sought, 
and,  deformity  having  begun,  is  very  difficult  to  check,  for  the  reasons 
that  have  been  already  stated. 

The  final  result  in  the  majority  of  cases  is  what  appears  to  be  ex- 
aggerated round  shoulders  ;  the  neck  is  shortened  and  projects  forward, 
the  chest  is  flat  and  the  shoulders  are  high. 

It  is  only  by  an  early  diagnosis  and  by  efficient  and  long  continued 
treatment  that  recovery  from  disease  in  this  region  without  noticeable 
deformity,  may  be  hoped  for. 

In  all  cases  of  disease  above  the  ninth  vertebra,  the  anterior  brace 
for  backward  traction  of  the  shoulders  may  be  used  with  great  advan- 
tage to  secure  greater  fixation  of  the  spine  ;  and  in  all  cases  above  the 
seventh  or  eighth  vertebra  a  head  or  chin  support  to  restrain  the  for- 
ward inclination  of  the  neck  is  indicated  in  addition. 

With  the  plaster  jacket  the  jury  mast  is  employed,  with  the  brace 
the  looped  chin  rest  or  the  ordinary  Taylor  support  may  be  used. 

In  disease  of  the  middle  and  upper  dorsal  region  the  brace  is  to 
be  preferred  to  the  jacket  because  of  the  greater  accuracy  of  adjust- 
ment, and  because  the  halter  of  the  jury  mast  is  rarely  retained  in 
proper  position  when  the  patient  does  not,  as  in  these  cases,  feel  the 
need  of  such  support. 

In  this  region  of  the  spine,  paralysis  frequently  occurs  as  a  compli- 
cation. When  it  appears  after  treatment  is  begun,  it  is  usually  a  result 
of  inefficient  fixation  of  the  spine  or  of  want  of  caution  in  regulating 
the  strain  to  which  the  diseased  part  is  subjected.  Its  symptoms 
and  its  treatment  will  be  considered  later. 

Disease  of  the  Upper  Dorsal  and  Middle  Cervical  Region. — This  is  the 
most  favorable  region  of  the  spine  for  treatment.  The  disease  is 
usually  not  extensive  because  of  the  small  size  and  compact  structure 
of  the  vertebrae ;  and  the  mobility  of  the  cervical  region  is  so  great 
that  it  readily  compensates  for  the  local  rigidity. 

Under  efficient  treatment  one  may  predict  recovery  without  notice- 
able deformity  and  in  the  less  successful  cases  the  deformity  is  not,  as 
a  rule,  offensive.  The  shoulders  appear  high,  the  neck  is  short,  the 
head  inclines  forward  while  the  back  is  abnormally  flat  in  compensa- 
tion for  the  change  in  contour  of  the  part  above. 

When  the  case  of  cervical  disease  is  first  brought  for  treatment,  a 
icry  neck  deformity,  often  made  more  persistent  by  the  infiltration  of 
an  abscess  or  by  inflamed  cervical  glands  is  almost  always  present. 
As  a  means  of  correcting  this  distortion,  the  jury  mast  and  traction 
halter,  attached  to  the  jacket  or  brace  is  a  very  efficient  and  comfortable 


86  TUBERCULOUS  DISEASE  OF  THE  SPINE. 

support.  Under  the  constant  tension  the  deformity  is,  as  a  rule,  very 
quickly  corrected,  but  as  a  permanent  treatment,  the  brace  and  head 
support  are  to  be  preferred  to  the  jury  mast,  because  a  more  exact  fixa- 
tion is  assured ;  for,  as  has  been  stated,  although  the  jury  mast,  when 
properly  applied  and  adjusted,  is  an  admirable  support,  yet  under  other 
conditions  it  is  absolutely  worthless. 

The  distortion  of  the  head  may  be  overcome  also  by  traction  in  bed, 
and  it  will  usually  disappear  under  simple  fixation.  The  use  of  col- 
lars of  felt  or  leather  has  been  mentioned.  With  the  brace  these  are 
unnecessars',  but  they  may  be  used  with  advantage  to  add  to  the  effi- 
ciency of  the  plaster  jacket  and  jury  mast. 

Disease  of  the  Occipito-Axoid  Region. — Under  efficient  treatment  the 
prognosis  is  good,  and  recovery  without  deformity  should  be  the  rule. 
The  course  of  the  disease,  although  it  is  often  accompanied  by  acute 
symptoms,  is  usually  short  as  compared  with  that  of  other  regions  of  the 
spine ;  and  it  may  be  assumed  that,  in  many  cases,  it  is  a  primary 
arthritis,  or  at  least  that  the  primary  focus  in  the  atlas  or  axis  is  very 
small.  The  disease  at  this  point  is  however  in  close  proximity  to  the 
vital  centers,  and  sudden  death  from  displacement  of  the  weakened 
parts  is  not  uncommon.  Abscess  is  frequent  and  it  is  often  a  trouble- 
some and  dangerous  complication. 

As  has  been  mentioned,  wry  neck  deformity  is  a  very  constant 
symptom,  and  there  is  also  a  strong  tendency  toward  a  forward  and 
downward  inclination  of  the  head,  so  that  in  neglected  cases  the  chin 
may  rest  upon  the  chest.  The  indications  for  treatment  are  to  over- 
come the  distortion  and  to  hold  the  head  fixed  in  the  middle  line,  the 
chin  being  somewhat  elevated  above  the  right-angled  relation  with  the 
spine.  In  the  mild  cases  the  jacket-and-jury-mast  traction  may  be 
used  to  overcome  the  distortion,  but  the  metallic  head  support  Avith  the 
fixation  attachment,  to  prevent  motion  in  the  diseased  joints,  is  always 
indicated  as  the  treatment  of  selection  because  by  such  apparatus  the 
danger  of  displacement  may  be  avoided. 

When  the  disease  is  acute  in  character,  and  especially  if  abscess  be 
present,  recumbency  on  the  frame  with  fixation  of  the  head  and  slight 
traction  by  the  weight  and  pulley,  or  by  the  jury  mast  attachment,  is 
indicated.  Traction  should  not  be  sufficient  to  cause  discomfort ; 
counter  traction  may  be  supplied  by  the  weight  of  the  body  and  by 
slight  elevation  of  the  head  of  the  bed.  The  head  sling  is  of  the  form 
used  with  the  jury  mast,  or  a  simple  band  about  the  head  may  be 
used.  Under  this  treatment  slight  deformity  of  any  part  of  the  cer- 
vical region  will  practically  disappear,  and  as  a  rule  the  course  of  the 
disease  is  very  favorably  influenced  by  it. 

In  certain  cases  of  disease  of  this  region,  accompanied  by  acute 
symptoms,  the  attitude  of  recumbency  is  extremely  uncomfortable. 
The  discomfort  is  caused  apparently  by  the  forward  projection  of  the 
upper  part  of  the  spine,  so  that  when  the  head  is  drawn  upward  and 
backward  in  the  recumbent  attitude  the  calibre  of  the  throat  is  lessened, 
lu  other  instances  the  pain  may  be  due  to  pressure  of  the  atlas  against 


THE  COMPLICATIONS  OF  POTT'S  DISEASE.  87 

the  odontoid  process  of  the  axis.  In  such  cases,  if  recumbency  is 
desiredj'the  head  must  be  elevated  by  pillows  to  the  point  of  comfort, 
the  support  being  removed  when  the  child  has  become  accustomed  to 
the  position,  or  when  the  deformity  has  been  corrected. 


The  Complications  of  Pott's  Disease. 

Abscess. — It  may  be  assumed  that  a  limited  collection  of  tuberculous 
fluid  is  present  at  some  time  during  the  course  of  Pott's  disease  in  the 
great  majority  of  cases,  but  unless  it  appears  as  a  palpable  tumor  above 
or  below  the  thorax  or  upon  the  surface  of  the  body  its  presence  is  not 
often  detected. 

Townsend,^  in  380  cases  of  Pott's  disease  examined  with  reference 
to  the  occurrence  of  abscess  as  a  complication,  found  that  it  was  pres- 
ent or  had  been  detected  in  75  (19.7  per  cent.),  in  8  per  cent,  of  the 
cases  of  cervical  disease,  in  20  per  cent,  of  the  dorsal  and  in  72  per 
cent,  of  those  in  which  the  lumbar  region  was  involved. 

Dollinger,^  in  700  cases  under  treatment  from  1883  to  1895  found 
abscess  in  154  (22  per  cent.) ;  in  13  of  63  cases  in  the  cervical  region 
(22.6  per  cent.)  ;  in  47  of  403  cases  in  the  thoracic  region  (11.6  per 
cent.)  and  in  94  of  234  cases  of  lumbar  disease  (40.17  per  cent.). 

Ketch,^  in  75  cured  cases  of  Pott's  disease  treated  at  the  N,  Y. 
Orthopaedic  Dispensary,  selected  for  the  purpose  of  contrasting  the  be- 
havior of  the  disease  in  the  different  regions  of  the  spine  found  that 
abscess  had  appeared  in  19  (25.3  per  cent.).  In  the  upper  region 
abscess  was  detected  in  but  one  of  the  25  cases  (4  per  cent.) ;  in  the 
middle  region  in  8  of  the  25  cases  (32  per  cent.)  and  in  the  lower 
in  10  (40  per  cent.). 

In  354  autopsies  by  Mohr,  Nebel  Bouvier  and  Lannelongue  abscess 
was  found  in  281  or  nearly  80  per  cent.  Although  cases  of  Pott's 
disease  that  come  to  autopsy  may  be  supposed  to  represent  a  severe 
type  of  disease  yet  it  is  evident,  by  contrasting  the  statistics,  that  a 
large  proportion  of  the  abscesses  escape  detection  in  the  living.  One 
may  conclude  then,  that  abscess  may  be  expected  as  a  more  or  less 
serious  complication  in  25  per  cent,  of  all  cases  of  Pott's  disease,  and 
in  at  least  half  of  those  in  which  the  lower  region  of  the  spine  is  in- 
volved, the  greater  frequency  here,  being  explained  by  the  large  size 
and  less  resistant  structure  of  the  vertebral  bodies,  as  compared  with 
those  of  the  upper  regions. 

The  tuberculous  abscess  is  separated  from  the  neighboring  parts  by 
a  limiting  wall  of  more  or  less  thickness,  according  to  its  age,  the 
outer  layers  of  which  are  of  fibrous  and  cellular  tissue,  the  inner  of 
granulation  tissue  covered  with  yellowish-gray  or  pinkish-gray  necrotic 
membrane  which  is  easily  separated  from  the  underlying  parts.  The 
fluid  of  the  abscess  is  of  a  whitish  or  whey-like  color  composed  of 

1  Trans.  Am.  Ortho.  Ass'n,  Vol.  IV.,  p.  166. 

2  Dollinger,  loc.  cit. 

"Trans.  Am.  Ortho.  Ass'n,  Vol.  IV.,  p.  200. 


88  TUBERCULOUS  DISEASE  OF  THE  SPINE. 

serum,  leucocytes  and  emulsified  caseous  material  and  fibrin  ;  floating  in 
it  are  larger  masses  of  cheesy  necrotic  tissue  and  sometimes  minute 
fragments  of  bone.  This  more  solid  material  settles  to  the  bottom  of 
the  glass  if  the  fluid  is  allowed  to  stand.  The  fluid  of  quiescent  ab- 
scesses or  those  that  are  in  process  of  resolution  is  often  clear,  like 
serum,  but  if  secondary  infection  has  taken  place  the  pus  is  of  a 
greenish-yellow  color,  and  is  of  uniform  consistency.  At  any  stage  of 
its  progress  the  abscess  may  become  stationary  and  its"  contents  may 
be  absorbed,  in  fact  such  an  outcome  is  not  unusual ;  the  fluid  of  the 
abscess  is  usually  sterile  and  secondary  infection,  before  a  communica- 
tion with  the  exterior  of  the  body  is  established,  is  comparatively  rare. 

It  has  been  claimed  that  abscess  formation  is  always  the  result  of 
infection  with  pyogenic  germs,  but  this  may  be  doubted,  since  the 
ordinary  tuberculous  abscess  may  be  sterile  or  at  most  contain  but  a 
few  tubercle  bacilli.  It  is  very  certain,  however,  that  the  formation 
and  increase  of  the  abscess  is  favored  by  irritation  and  injury,  and 
that  the  most  effective  treatment  of  this  complication  is  to  support  the 
diseased  spine  and  to  relieve  it  from  over-strain. 

Abscess  is  a  symptom  of  disease  and  is,  in  some  degree,  an  evidence 
of  its  character.  If  it  appears  early  and  increases  in  size  rapidly,  it 
usually  indicates  a  destructive  and  rapidly  advancing  process,  or  infec- 
tion from  without.  On  the  other  hand,  the  slowly  enlarging  or  quies- 
cent abscess  has  but  little  significance. 

In  many  instances  the  abscess  causes  no  symptoms  whatever,  or  it 
may  be  a  source  of  inconvenience  simply  because  of  its  size  or  situa- 
tion. In  other  cases,  a  period  of  malaise  or  discomfort  or  pain  is  fol- 
lowed and  explained  by  the  appearance  of  an  abscess,  but  whether  the 
symptoms  were  caused  by  the  tension  of  the  abscess  or  by  a  more  acute 
phase  of  the  disease  itself,  is  not  always  clear. 

Large  abscesses,  which  are  increasing  in  size  and  approaching  the 
surface  are  usually  accompanied  by  pain,  and  by  elevation  of  temper- 
ature, that  indicates  probably  a  slight  degree  of  secondary  infection, 
but  otherwise  the  ordinary  deep  abscess  appears  to  have  no  other  ef- 
fect than  to  add,  doubtless,  to  the  susceptibility  of  the  patient. 

The  Course  and  Peculiarities  of  Abscess  in  the  Different  Regions  of  the 
Spine. — The  tuberculous  abscess  may  remain  as  a  small  collection  of 
fluid  in  the  neighborhood  of  the  disease  where  its  presence  may  be  de- 
tected only  by  percussion  or  by  deep  palpation.  As  a  rule,  however, 
it  slowly  increases  in  size,  and  under  the  influences  of  the  force  of 
gravity  and  the  tension  of  its  contents  it  finds  its  way  down  the  spine 
or  toward  the  exterior  of  the  body,  following  the  path  of  least  resistance. 
The  abscesses  which  have  passed  below  the  diaphragm  or  which  have 
originated  below  this  point  may  follow  various  paths.  Some  enter  the 
sheath  of  the  psoas  muscle  and  finally  make  their  appearance  on  the 
inner  aspect  of  the  thigh,  psoas  abscess.  Others  perforate  the  sheath 
of  the  quadratus  lumborum  muscle  and  form  a  lumbar  abscess  projecting 
between  the  twelfth  rib  and  the  crest  of  the  ilium  at  the  triangle  of 
Petit.     Those  abscesses  that  escape  from  the  fascia  of  the  psoas  muscle 


THE  COMPLICATIONS   OF  POTT'S  DISEASE. 


89 


or  that  pass  downward  on  the  surface  of  the  iliac  fascia,  the  so-called 
iliac  abscesses,  often  form  a  tumor  over  the  outer  extremity  of  Pou- 
part's  ligament  at  the  junction  of  the  transversalis  and  iliac  fasciae,  or 
the  fluid  may  follow  the  course  of  the  iliac  artery  to  the  thigh,  or, 
escaping  from  the  greater  sacro-sciatic  foramen,  form  a  gluteal  abscess. 

Iliac  or  psoas  abscess  is  most  often  confined  to  one  side  but  it 
may  be  bilateral,  the  two  sacs  communicating  with  one  another  by  a 
larger  or  smaller  channel.  In  the  thoracic  region  the  abscess  may  re- 
main indefinitely  in  the  posterior  mediastinum,  where,  if  large,  its 
presence  may  be  demonstrated  by  an  area  of  dullness  extending  toward 
the  lateral  region  of  the  thorax 

or  it  may  perforate  the  inter-  Fig.  56. 

costal  muscles  and  appear  on 
the  posterior  or  lateral  aspect 
of  the  chest,  or  it  may  pass 
downward  through  the  aortic 
opening  in  the  diaphragm  and 
become  an  iliac  abscess. 

Abscess  caused  by  disease  of 
the  occipito-axoid  region  may 
force  its  w^ay  forward  between 
the  recti  muscles  and  appear 
behind  the  pharynx  as  the 
retro-pharyngeal  abscess,  or  the 
fluid  may  take  the  opposite  di- 
rection and  distend  the  sub- 
occipital triangle  and  then  pass 
forward  to  the  region  of  the 
mastoid  process.  In  other  in- 
stances the  abscess  may  dissect 
its  way  about  the  base  of  the 
skull  or  pass  upwards  through 
the  foramen  magnum  or  down- 
ward into  the  spinal  canal. 

Abscesses  from  the  middle 
cervical  region  usually  pass  out- 
ward between  the  scaleni  and 
longus  colli  muscles  to  the  inter- 
val between  the  trapezius  and  sterno-mastoid,  perforating  the  skin 
about  the  middle  of  the  lateral  aspect  of  the  neck  near  the  anterior 
border  of  the  latter  muscle. 

These  are  the  paths  usually  followed  by  the  tuberculous  fluid,  but 
occasionally  it  may  enter  the  spinal  canal  or  break  into  the  pleural 
cavity  or  lung  or  intestine  or  by  the  side  of  the  rectum  or  elsewhere. 

Treatment  of  Abscess. — Abscess  is  by  far  the  most  troublesome  and 
dangerous  complication  of  Pott's  disease.  It  may  interfere  with  proper 
mechanical  treatment,  and  it  is  often  a  cause  of  permanent  as  well  as 
temporary  deformity,  especially  in  the  lower  region  of  the  spine  as 


Bilateral  lumbar  abscess. 


90  TUBERCULOUS  DISEASE  OF  THE  SPINE. 

has  been  stated.  It  prolongs  the  course  of  the  disease  by  extending 
its  boundaries  and  although  it  is  not  often  a  direct  cause  of  death,  yet 
many  patients  die  because  of  the  exhaustion  of  long-continued  suppura- 
tion that  may  follow  secondary  infection  and  of  the  amyloid  degenera- 
tion that  may  finally  result. 

A  large  abscess  is  always  a  source  of  danger  because  of  the  possi- 
bility of  secondary  infection  of  its  contents  before  it  finds  an  outlet 
and  because  of  the  probability  of  infection,  when  a  communication 
with  the  exterior  has  been  established.  Abscess  is  however  a  symptom 
and  result  of  disease  and  in  properly  treated  cases  it  is  as  a  rule  a 
complication  of  comparatively  slight  consequence.  If  abscess  is  not 
present  when  treatment  is  begun,  one  may  hope  to  prevent  it  by  efFec- 
tive  protection  of  the  spine,  and  if  it  be  present,  this  protection  should 
be  all  the  more  rigidly  enforced. 

The  surgical  treatment  of  the  abscess  of  spinal  disease  is  very  diffi- 
cult, not  because  it  is  different  in  character  from  other  tuberculous  ab- 
scesses, but  because  it  is  as  a  rule  impossible  to  remove  the  disease  of 
which  the  abscess  is  a  symptom  ;  and  incomplete  or  ineffective  surgi- 
cal operations  should  be  avoided. 

As  the  abscess  is  a  symptom  of  disease  so,  as  a  rule,  its  treatment 
should  be  symptomatic.  The  retro-pharyngeal  abscess  demands  prompt 
evacuation  because  it  is  likely  to  obstruct  breathing  and  swallowing, 
because  its  sudden  rupture  may  cause  death  and  because  an  abscess  in 
such  close  proximity  to  the  vital  centers  is  always  a  source  of  danger. 
In  cases  of  emergency  the  abscess  may  be  evacuated  by  an  incision  in 
the  middle  line  of  the  pharynx,  but  preferably  the  opening  should  be 
from  the  exterior.  An  incision  is  made  along  the  posterior  aspect  of 
the  sterno-mastoid  muscle  in  its  upper  third.  The  abscess  tumor  is 
easily  reached  by  careful  dissection  and  drainage  is  established  which 
has  evident  advantages  over  that  into  the  throat. 

Abscesses  from  the  middle  cerviccd  region  usually  point  in  the  lat- 
eral region  of  the  neck  and  cause  but  little  inconvenience.  Abscesses 
in  the  upper  thoracic  region  may,  in  rare  instances,  cause  dangerous 
pressure  on  the  trachea  or  lungs  as  shown  by  spasmodic  attacks  of  in- 
spiratory dyspnoea,  "  asthmatic  attacks."  In  some  instances  an  area 
of  dullness  near  the  seat  of  disease  demonstrates  the  position  of  the 
abscess,  but  if  it  lies  in  the  median  line  it  can  not  be  detected  either 
by  auscultation  or  percussion.  If  the  inspiratory  dyspnoea  is  well 
marked  the  symptom  may  be  fairly  attributed  to  this  cause  and  the 
operation  of  costo-transversectomy  may  be  undertaken  to  relieve  the 
pressure.  An  incision  is  made,  preferably  on  the  right  side,  to  expose 
the  articulation  between  the  transverse  process  and  the  rib ;  the  joint 
may  be  resected  or  a  section  from  one  or  more  of  the  ribs  may  be  re- 
moved as  in  the  operation  for  empyaema ;  the  finger  is  then  inserted 
and  passed  along  the  surface  of  the  adjacent  vertebral  body  until  the 
abscess  sac  is  reached.     It  is  then  opened  and  drained.     (Fig.  9.) 

In  the  lower  region  of  the  spine  operations  may  be  necessary  be- 
cause there  is  evidence  of  secondary  infection.     In  this  event  if  the 


THE  COMPLICATIONS   OF  POTT'S  DISEASE.  91 

abscess  distends  the  lumbar  region  or  forms  a  sac  on  either  side  of 
the  spine,  an  opening  in  the  loin  on  one  or  both  sides  of  the  spine  is 
necessary.  This  is  made  as  in  operations  on  the  kidney,  by  an  incision 
on  the  outer  side  of  the  erector  spinse  muscle  between  the  last  rib  and 
the  crest  of  the  ilium ;  the  underlying  quadratus  lumborum  muscle  is 
<!ut  through  transversely  and  the  abscess  cavity  is  entered.  In  certain 
cases,  it  is  possible  to  expose  the  spine  and  to  remove  fragments  of 
necrosed  bone  along  with  the  contents  of  the  abscess.  As  a  rule  the 
complete  removal  of  the  lining  membrane  of  the  abscess  is  not  pos- 
sible, and  one  must  be  content  to  evacuate  the  solid  and  semi-solid 
contents  by  flushing  with  hot  water,  together  with  as  much  of  the 
abscess  membrane  as  may  be  removed  by  swabbing  with  gauze.  The 
most  important  point  in  the  operation  is  to  provide  for  efficient  and 
complete  drainage  of  the  cavity ;  if  this  is  assured  there  is  little 
danger  to  be  apprehended  from  subsequent  infection.  Two  or  more 
counter  openings  are  usually  necessary  when  the  lumbar  incision  has 
been  made,  one  just  in  front  of  the  anterior  superior  spine  and  another 
in  the  thigh,  if  the  abscess  is  of  the  psoas  variety.  Long  drainage 
tubes  are  inserted  and  should  remain  until  a  proper  channel  for  the 
escape  of  pus  has  been  established. 

When  the  abscess  is  of  one  side  only,  not  extending  into  the  thigh, 
and  when  the  symptoms  do  not  indicate  infection,  but  when  its  evacu- 
ation seems  advisable  because  of  its  size  and  tension,  it  may  be  opened 
by  an  anterior  incision  below  Poupart's  ligament  just  to  the  inner  side 
of  the  sartorius  muscle.  After  copious  injections  of  hot  water  a  drain- 
age tube  may  be  inserted  long  enough  to  reach  to  the  seat  of  disease  if 
it  be  of  the  lumbar  region. 

In  after-treatment  irrigation  is  not  often  required ;  the  dressing 
should  be  of  dry  sterile  gauze  and  great  attention  should  be  paid  to 
absolute  cleanliness  and  to  effective  drainage.  As  soon  as  is  possible, 
if  the  discharge  has  become  slight  and  if  the  back  can  be  properly 
supported,  the  patient  is  allowed  to  walk  about  and  to  go  into  the  open 
air.  In  ordinary  cases  a  slight  discharge  will  persist  for  several 
months  or  longer,  depending  on  the  condition  of  the  disease ;  if  how- 
ever it  be  quiescent  or  cured  the  sinus  will  promptly  close. 

In  the  symptomatic  treatment  of  abscess,  aspiration  is  sometimes  of 
service,  for  by  this  means  it  may  be  prevented  from  increasing  in  size  ; 
and  when  the  disease  is  quiescent,  the  cure  of  the  abscess  may  follow 
the  removal  of  its  contents  wliich  allows  the  collapse  of  its  walls. 
When  aspiration  is  employed  it  should  be  repeated  systematically  as 
often  as  the  abscess  cavity  refills.  After  each  evacuation  pressure 
should  be  applied  to  favor  the  adhesion  of  the  apposed  walls. 

When  the  contents  are  of  such  a  nature  that  aspiration  is  impracti- 
cable, an  incision  may  be  made,  through  which  the  semi-solid  substance 
may  be  removed  by  vigorous  flushing  with  hot  water.  The  opening 
is  then  closed  and  pressure  is  applied  with  the  aim  of  obtaining  pri- 
mary union.  This  method  is  sometimes  successful,  but  usually  a  sinus 
forms  later  at  the  point  of  incision. 


92  TUBERCULOUS  DISEASE  OF  THE  SPINE. 

Until  recently  the  injection  of  anti-tuberculous  remedies  into  the  ab- 
scess sac  was  in  favor.  This  is  probably  of  value  in  diminishing 
the  infective  quality  of  the  contents,  perhaps  also,  in  lessening  the 
danger  of  mixed  infection  and  in  stimulating  absorption,  although  it 
appears  to  have  little  direct  effect  upon  the  course  of  the  tubercu- 
lous process.  An  emulsion  of  iodoform  in  sterilized  oil  or  glycerine, 
10-20  per  cent,  in  doses  of  from  4-30  grammes  is  injected  at  intervals 
of  from  two  to  four  weeks,  with  or  without  previous  evacuation  of  the 
contents ;  the  amount  and  the  frequency  of  the  injection  depending 
upon  the  age  of  the  patient  and  upon  the  effect  of  the  treatment.  If 
used  with  caution  as  to  asepsis,  and  to  the  toleration  of  the  patient  for 
iodoform,  no  harm  will  follow,  even  if  the  treatment  proves  to  be  of 
little  practical  value. 

When  an  abscess  approaches  the  surface,  the  skin  becomes  red  and 
thin  and  there  is  usually  some  local  tenderness  and  pain.  Whenever 
spontaneous  evacuation  of  the  abscess  is  probable,  the  mother  should 
be  instructed  as  to  the  necessity  of  absolute  cleanliness,  and  the  proper  . 
dressings  should  be  provided.  After  the  abscess  has  broken,  the  patient 
should  remain  in  bed  for  several  days,  or  until  the  discharge  has  be- 
come small  in  amount. 

In  the  symptomatic  treatment  of  the  abscesses  of  Pott's  disease,  we 
may  conclude  then  that  operation  will  be  indicated  in  the  treatment  of 
the  retro-pharyngeal  abscess  and  in  the  rare  instances  when  dangerous 
pressure  is  exerted  by  an  abscess  in  the  posterior  mediastinum.  It  is 
indicated  of  course  when  there  is  evidence  of  mixed  infection  or  when 
the  rapidly  increasing  abscess  causes  discomfort,  or  interferes  with  ef- 
fective support.  It  is  usually  indicated  when  the  abscess  is  of  large 
size  if  proper  care  can  be  provided.  The  operative  treatment  is  practi- 
cally free  from  danger  if  cleanliness  and  efficient  drainage  can  be  assured. 
Aspiration  is  practically  free  from  danger  and  is  often  of  service  in  pre- 
venting the  enlargement  of  the  abscess  and  it  may  hasten  its  absorption. 

While  the  operative  treatment  of  large  abscesses  is,  under  proper 
conditions,  free  from  danger  and  is  likely  to  become  the  treatment  of 
selection  and  routine  in  those  cases  for  which  efficient  after-treatment 
can  be  provided,  yet  in  the  majority  of  cases  the  symptomatic  treat- 
ment that  has  been  outlined  is  likely  to  hold  a  permanent  place,  since 
in  large  cities  there  are  far  more  patients  who  have  abscesses  than 
there  are  hospital  beds  to  put  them  in.  Treatment  under  such  limita- 
tions has  demonstrated  the  fact  that  the  abscess  is  of  little  consequence 
when  the  primary  disease  has  been  properly  treated.  An  abscess  often 
exists  for  mouths  before  its  presence  is  detected  and  after  its  discovery 
it  may  remain  quiescent  for  a  long  time  and  finally  disappear. 

A  very  large  proportion  of  the  abscesses  of  Pott's  disease  cause  no 
symptoms,  but  slowly  find  their  way  to  the  surface  of  the  body.  Mean- 
while it  may  be  assumed  that  the  disease  of  the  spine,  of  which  the  ab- 
scess is  a  result,  is  in  process  of  cure ;  so  that  when  the  fluid  finds  an 
outlet,  the  source  of  supply  will  be  shut  off  and  permanent  closure  of 
the  sinus  may  follow. 


FREQUENCY  OF  PARALYSIS.  93 

Finally  a  discharging  sinus  communicating  with  the  interior  of  the 
body,  whether  it  be  the  result  of  an  operation  or  not,  is  always  a 
source  of  discomfort.  It  may  interfere  with  eifective  support,  and  if 
the  discharge  is  large  in  amount  it  is  much  more  serious  in  its  effect 
upon  the  patient  than  was  the  abscess  when  it  was  contained  in  the 
interior  of  the  body. 

These  are  practical  arguments  that  are  particularly  eifective  Avhen 
contrasted  with  the  evidence  in  favor  of  the  so-called  radical  treatment 
that  consists  in  the  evacuation  of  every  collection  of  fluid  because  it 
is  an  abscess,  without  regard  to  the  general  condition  of  the  patient  or 
to  the  local  disease  of  the  bone  of  which  it  is  a  complication. 

Paralysis  from  Pott's  Disease. 

The  tuberculous  process  in  the  vertebral  bodies  may  extend  back- 
ward and  breaking  through  the  posterior  ligament  it  may  enter  the 
epidural  space  and  press  upon  the  spinal  cord ;  then  follows  paresis  or 
paralysis  of  the  parts  below  the  constriction.  In  rare  instances  the 
pressure  may  be  due  to  a  fragment  of  necrosed  bone.  Not  infrequently 
it  is  caused  in  part  at  least  by  the  pressure  of  a  neighboring  abscess, 
but  it  is  usually  the  result  of  the  slow  advance  of  the  tuberculous 
granulation  tissue.  When  this  has  forced  an  entrance  into  the  spinal 
canal  it  sets  up  a  resistant  inflammatory  thickening  of  the  coverings 
of  the  cord,  first  a  peripachymeningitis  and  then  a  pachymeningitis, 
so  that  in  addition  to  the  direct  pressure  there  may  be  an  interference 
with  the  blood  supply  and  with  the  lymphatic  circulation.  Thus  local 
oedema  of  the  cord  may  follow  and  as  a  later  result  an  increase  in  the 
interstitial  connective  tissue  of  its  substance  with  a  corresponding 
atrophy  of  the  nervous  elements ;  an  ascending  and  descending  de- 
generation that,  in  prolonged  cases,  may  terminate  in  partial  or  com- 
plete sclerosis.  The  dura  mater  is  a  resistant  structure  and  direct 
destruction  of  the  cord  by  the  tuberculous  disease  is  rare.  In  fact,  as 
a  rule  but  little  permanent  damage  results  even  from  long-continued 
pressure  and  paralysis,  for  the  cord  seems  in  these  cases  to  possess  the 
power  of  repair  and  regeneration  to  a  remarkable  degree. 

The  calibre  of  the  spinal  canal  is  not  usually  lessened  by  the  char- 
acteristic angular  distortion  of  the  back,  although  the  weight  and  for- 
ward inclination  of  the  trunk  may  force  the  softened  tissues  backward 
against  the  cord  and  thus  increase  the  direct  pressure  ;  in  fact  paralysis 
is  much  more  often  associated  with  a  slight  or  moderate  kyphosis  than 
with  extreme  deformity. 

Frequency  of  Paralysis. — In  1,670  cases  of  Potf  s  disease  recorded 
at  the  New  York  Orthopaedic  Dispensary,  paralysis  occurred  in  218,^ 
and  in  445  cases  in  the  private  practice  of  Dr.  C.  F.  Taylor,^  59  cases 
of  paralysis  were  observed.  Thus  in  a  total  of  2,015  cases  of  Pott's 
disease  there  were  279  cases  of  paralysis  or  13.7  per  cent. 

'Myers,  Trans.  Am.  Ortho.  Ass'n,  Vol.  III.,  1891,  p.  209. 
2  Taylor  and  Lovett,  N.  Y.  Med.  Kecord,  June  19,  1896. 


94  TUBERCULOUS  DISEASE  OF  THE  SPINE. 

This  proportion  is  much  larger  than  the  normal  however,  for  many 
of  the  patients  were  taken  to  the  specialist  or  to  the  special  hospital 
because  of  the  paralysis,  as  in  40  of  Taylor's  and  in  133  of  the  Dis- 
pensary cases.  If  these  be  excluded,  the  percentage  of  paralysis  oc- 
curring in  those  actually  under  treatment  is  reduced  to  5.6  per  cent. 
This  percentage  corresponds  very  closely  to  that  of  Dollinger/  viz.: 
41  cases  of  paralysis  in  700  cases  of  Pott's  disease  under  treatment 
(5.8  per  cent.),  and  it  may  be  accepted  as  representing  the  average 
liability  to  paralysis  among  those  who  have  received  treatment  for 
Pott's  disease,  the  percentage  being  much  higher  in  neglected  cases. 

The  Liability  to  Paralysis  in  Disease  of  the  Different  Regions 
of  the  Spine. — The  liability  to  paralysis  is  very  much  greater  in  dis- 
ease of  certain  regions  of  the  spine  than  in  others. 

Thus  105  of  the  209  cases  in  Myers's  list,  in  which  the  situation  of 
the  disease  was  recorded,  complicated  disease  of  the  dorsal  region  above 

Fig.  57. 


Pott's  paraplegia  before  the  stage  of  deformity.     Tlie  same  patient  is  sliown  in  Fig.  47. 

the  eighth  vertebra.  Of  the  remainder,  in  16  the  disease  was  of  the 
cervical  region  ;  in  12  of  the  cervico-dorsal  and  in  59  of  the  lower 
dorsal  and  dorso-lumbar  regions. 

37  of  Taylor's  59  cases  were  caused  by  disease  of  the  dorsal  region  ; 
8  occurred  in  the  cervical  and  cervico-dorsal,  and  11  in  the  dorso- 
lumbar  and  lumbar  regions. 

26  of  the  total  of  41  cases  recorded  by  Dollinger  were  caused  by 
disease  of  the  third  to  the  seventh  dorsal  vertebrae  inclusive,  or  about 
23  per  cent,  of  the  cases  in  which  this  region  was  involved. 

In  132  cases  of  paraplegia  reported  by  Gibney,^  not  one  complicated 
disease  of  the  lumbar  region  ;  nearly  all  were  caused  by  compression 
in  the  middle  or  upper  dorsal  segment. 

These  statistics  show  that  the  upper  and  middle  dorsal  section  is 
the  point  of  greatest  liability  to  paralysis,  a  fact  that  is  explained 
possibly  by  the  smaller  size  of  the  canal  at  this  point,  and  by  the  dif- 
ficulty in  assuring  complete  fixation  at  the  seat  of  disease.     In  this 

'  Loc.  cit. 

2  Journal  of  Nervous  and  Mental  Diseases,  Jan.  5,  1897 


SYMPTOMS  OF  POTT'S  PARAPLEGIA.  95 

region  it  may  be  estimated  that  15  per  cent,  of  the  cases  of  Pott's  dis- 
ease will-be  complicated  by  paralysis  before  cure  is  established. 

Prognosis. — In  properly  treated  cases  the  prognosis  is  very  favor- 
able. The  final  results  of  47  of  the  59  cases  of  paraplegia  in  Taylor's 
practice  were  ascertained.  Of  these  39  recovered  completely,  5  died  of 
intercurrent  disease  while  apparently  recovering  and  in  3  the  recovery 
was  partial. 

Of  the  hospital  cases  recorded  by  Myers,  3  per  cent,  died  of  inter- 
current disease.  The  final  results  could  be  ascertained  in  but  55  per 
cent,  of  the  patients  who  remained  under  treatment.  All  of  these  re- 
covered. 

In  74  cases  of  paraplegia  treated  by  Gibney,^  45  were  cured,  12 
improved,  8  unimproved  and  9  died.  Thus  77  per  cent,  were  cured 
or  improved ;  and  in  a  similar  series  of  40  cases  reported  by  Shaffer 
80  per  cent,  were  cured  and  but  10  per  cent,  of  the  remainder  were 
considered  as  hopeless  cases. 

Recurrence  of  paralysis  after  recovery  is  not  infrequent ;  in  18  cases 
such  recurrences  from  one  to  four  times  are  recorded  by  Myers,  and 
seven  successive  attacks  of  paralysis  were  observed  in  a  patient  under 
treatment  at  the  Hospital  for  Ruptured  and  Crippled. 

The  relapses  depend  upon  the  situation  or  upon  the  renewed  activ- 
ity of  the  disease  and  are  often  explained  by  the  neglect  of  protective 
treatment. 

Duration. — In  exceptional  cases  the  paralysis  appears  to  be  caused 
by  temporary  pressure  or  simply  to  disturbance  of  the  circulation  of 
the  cord,  due  possibly  to  the  pressure  of  the  superincumbent  weight 
upon  the  softened  and  diseased  tissues,  as  it  disappears  almost  immedi- 
ately when  the  spine  is  straightened  and  supported.  Usually  the  par- 
alysis remains  for  several  months,  not  infrequently  it  lasts  a  year,  and 
partial  or  even  complete  recovery  is  possible  after  a  much  longer  time. 
Recovery  from  the  paralysis  depends  upon  the  course  of  the  disease  of 
which  it  is  a  symptom,  upon  the  absorption  and  organization  of  the 
tuberculous  granulations  that  press  upon  the  cord  and  upon  the  regen- 
erative changes  in  its  structure,  if  it  has  been  implicated  in  the  disease. 

Time  of  Onset. — In  exceptional  cases  the  paralysis  may  precede  de- 
formity and  it  may  be  the  first  symptom  that  attracts  attention  to  the 
disease.  In  14  of  74  cases  reported  by  Gibney,  the  paralysis  was 
present  when  the  bone  disease  was  recognized,  but  it  is  probable  that 
the  primary  disease  had  existed  for  several  months  before  the  appear- 
ance of  the  paralysis.  Usually  it  is  a  comparatively  late  symptom, 
appearing  after  the  stage  of  deformity  and  more  often  from  6  to  12 
months  after  the  recognition  of  the  disease,  but  its  appearance  may  be 
deferred  until  long  after  apparent  cure. 

Symptoms  of  Pott's  Paraplegia. — The  most  marked  effect  of  the 
pressure  on  the  cord  is  the  interference  with  its  conductivity  ;  thus  the 
reflex  centers  situated  below  the  point  of  constriction,  relieved  from 
the  inhibition  of  the  brain,  become  over-active,  while  voluntary  mo- 
tion of  the  parts  below  the  constriction  is  difficult  or  impossible. 

^  Loc.  cit. 


96  TUBERCULOUS  DISEASE  OF  THE  SPINE. 

The  pressure  of  the  diseased  products  is  more  directly  upon  the 
antero-lateral  columns  so  that  motion  is  much  more  often  primarily 
aifected  than  is  sensation. 

The  early  symptoms  of  Pott's  paraplegia,  as  noticed  by  the  patient  or 
his  friends,  are  weakness,  awkwardness  and  a  stumbling,  shambling  gait. 
The  symptoms  usually  increase  rapidly  until  paralysis  of  motion  is  com- 
plete. At  this  stage  the  patella  tendon  reflex  is  increased  and  ankle 
clonus  is  often  present.  As  a  rule  both  legs  are  affected  in  equal  degree, 
but  occasionally  paralysis  of  one  leg  may  precede  that  in  the  other ;  or 
in  the  stage  of  recovery  power  may  return  more  rapidly  in  one  limb 
than  in  the  other.  The  limbs  in  the  early  stage  of  the  paralysis  may 
appear  limp  and  powerless,  but  when  the  patient  is  moved  or  when  the 
reflexes  are  stimulated  the  peculiar  spastic  rigidity  or  stiflness  appears. 

As  a  rule  the  rigidity  increases  with  the  duration  of  the  disease  and 
spastic  contractions  are  often  present ;  thus  the  thighs  may  be  approx- 
imated, the  knees  flexed  and  the  feet  extended.  Persistent  contrac- 
tions indicate,  as  a  rule,  permanent  damage  to  the  cord,  and  at  this 
stage  complete  recovery  is  infrequent. 

Sensation  is  retained  in  the  mild  cases,  but  in  the  more  severe  or 
prolonged  cases  it  may  be  impaired  or  lost.  •  Sensation  was  retained 
througliout  in  24  of  the  40  cases  reported  by  Shaffer. 

In  the  cases  of  partial  paralysis,  control  of  the  bladder  may  be  re- 
tained, but  usually  there  is  incontinence.  As  the  bladder  fills  the 
reflex  center  is  excited  and  it  empties  itself.  The  control  of  the 
sphincter  ani  is  less  often  or  Less  noticeably  affected. 

As  the  paralysis  is  the  result  of  more  active  or  of  advancing  disease, 
its  onset  may  be  preceded  by  an  increase  of  pain  ;  thus  greater  dis- 
comfort attended  by  an  increase  in  the  patella  tendon  reflex  may  be 
considered  as  an  indication  for  enforced  rest  of  the  individual,  although 
increased  activity  of  the  reflexes  is  not  uncommon  during  the  more 
active  stage  of  the  disease  without  apparent  involvement  of  the  spinal 
cord.  When  paralysis  occurs  in  patients  who  are  under  treatment  for 
Pott's  disease  the  onset  is  not,  as  a  rule,  attended  by  noticeable  or  un- 
usual pain,  the  reflected  pain  or  nerve  root  symptoms,  so  often  de 
scribed,  do  not  differ  from  the  ordinary  pain  of  Pott's  disease ;  ii 
many  cases  such  symptoms  are  lacking,  nor  is  pain  usually  complained 
of  after  the  paralysis  has  developed. 

The  extent  of  the  paralysis  depends  upon  the  situation  of  the  disease. 
In  exceptional  cases,  when  the  cervical  cord  is  implicated,  both  the 
arms  and  legs  may  be  paralyzed ;  this  occurred  in  seven  of  the  cases 
reported  by  Myers.  As  a  rule,  however,  the  paralysis  is  a  complica- 
tion of  disease  of  the  dorsal  region,  above  the  reflex  centers  in  the 
lumbar  enlargement  of  the  cord,  but  below  the  nerve  supply  of  the 
upper  extremities.  If  the  disease  were  at  a  lower  point,  for  example 
in  the  dorso-lumbar  section,  so  that  these  reflex  centers  themselves 
were  directly  implicated,  then  reflex  activity  would  not  be  increased, 
and  intermittent  incontinence  would  be  replaced  by  constant  dribbling 
of  urine ;  or  if  the  cauda  equina  alone  were  implicated  in  disease  of 


m 


TREATMENT.  97 

the  lumbo-sacral  region,  the  symptoms  would  be  those  of  neuritis,  pain, 
numbness  and  weakness  in  the  area  supplied  by  the  affected  nerves. 

In  ordinary  cases,  the  nutrition  of  the  limbs  is  not  greatly  affected, 
nor  do  the  contractions  become  permanent,  but  when  the  paralysis  is 
prolonged,  and  when  sensation  is  lost,  the  muscles  waste,  the  circula- 
tion is  impaired,  and  fixed  distortions  usually  appear.  But  even  in 
the  more  prolonged  and  severe  forms  of  paralysis,  occurring  in  child- 
hood, bedsores  are  rarely  seen. 

Treatment. — The  treatment  of  the  paralysis  is  included  in  the 
treatment  of  the  disease  of  which  it  is  a  symptom,  except  that  even 
greater  care  should  be  exercised  to  assure  fixation  of  the  spine. 

Rest  in  the  horizontal  position  on  the  Bradford  frame  is  indicated, 
and  over-extension  of  the  spine  should  be  aimed  at  by  bending  the 
side  bars  in  the  manner  described.  Direct  traction  by  the  weight  and 
pulley  should  be  used  if  the  disease  is  in  the  upper  dorsal  or  cervi- 
cal regions.  The  back  brace,  in  addition  to  the  frame,  assures  addi- 
tional fixation,  and  should  be  used  if  possible.  If,  however,  the  brace 
has  been  worn  before  the  paralysis,  its  shape  must  be  modified  to  ac- 
commodate the  change  in  the  outline  of  the  spine,  induced  by  recum- 
bency and  extension. 

Manipulation  or  massage  of  the  limbs  is  contraindicated  because  it 
stimulates  the  reflex  centers.  If  constant  contractions  of  the  muscles  are 
present,  the  deformity  may  be  reduced  by  traction  applied  in  the  ordi- 
nary manner  (Fig.  28),  or  a  fixation  brace  may  be  worn.  The  spasmodic 
contractions  are  often  painful,  and  if  the  paralysis  is  complicated  by 
tuberculous  joint  disease,  extension  and  fixation  combined  may  be 
indicated  to  relieve  the  joint  from  the  injury  of  involuntary  motion. 

Counter-irritation  at  the  seat  of  disease  was  by  Pott  considered  of 
the  greatest  value,  and  the  application  of  the  actual  cautery  from  time 
to  time,  about  the  kyphosis,  seems  in  certain  cases  to  exert  a  favorable 
influence  on  the  underlying  disease. 

Electricity,  particularly  galvinism,  has  been  used  and  it  is  of  some 
service  in  preserving  the  nutrition  of  the  limbs.  Its  value  in  a  case 
must  be  judged  by  its  effect. 

Of  the  internal  remedies  the  most  useful  seems  to  be  iodide  of  potas- 
sium. It  is  supposed  to  act  upon  the  tuberculous  granulation  tissue 
as  upon  the  products  of  syphilitic  disease.  A  convenient  method  of 
administration  is  a  solution  of  which  one  drop  represents  one  grain  of 
the  drug.  This  is  given  in  milk  or  in  Vichy  water  beginning  with 
five  drops  three  times  daily  and  increasing  the  dose  a  drop  each  day 
until  the  point  of  toleration  is  reached. 

The  first  indication  of  improvement  is  usually  lessening  of  the 
muscular  rigidity ;  then  the  ability  to  move  a  toe  is  regained,  after 
which  recovery  follows  quickly.  At  this  stage  massage  of  the  limbs 
may  be  employed  with  advantage.  The  exaggerated  reflexes  may  per- 
sist long  after  recovery,  in  fact,  as  has  been  stated,  this  symptom  is  not 
uncommon  among  patients  suffering  from  dorsal  Pott's  disease  who 
have  never  been  paralyzed. 
7 


98  TUBERCULOUS  DISEASE  OF  THE  SPINE. 

The  Operative  Treatment. — The  operation  of  laminectomy  was  at 
one  time  in  favor  but  it  has  now  been  jDractically  abandoned,  as  a 
treatment  of  routine  at  least,  for  the  paraplegia  of  Pott's  disease ;  be- 
cause it  has  been  proved  that  recovery,  if  somewhat  long  deferred,  is 
the  rule  without  operation  while  the  direct  death  rate  of  the  operation 
is  at  least  20  per  cent.  In  134  cases  collected  by  Rhein  ^  the  imme- 
diate mortality  (those  dying  within  a  month  after  the  operation)  was 
36  per  cent. 

Laminectomy  is  an  incomplete  operation  in  the  sense  that  the  dis- 
ease of  the  bone  is  not  removed,  and  recurrence  of  paralysis  and  ex- 
tension of  the  disease  are  not  infrequent  after  a  successful  immediate 
result.  It  should  be  reserved  for  those  cases  in  which  after  a  thorough 
and  prolonged  trial  of  ordinary  methods  the  condition  does  not  im- 
prove. Eighteen  months  has  been  suggested  as  the  proper  time  in  which 
to  test  conservative  treatment.  The  operation  may  be  indicated  also 
if  the  symptoms,  in  spite  of  treatment,  increase  in  severity,  and  when 
there  is  evidence  that  the  integrity  of  the  cord  is  threatened,  or  when  the 
paralysis  is  of  sudden  onset,  or  when  displacement  of  bone  or  pressure 
from  an  abscess  seems  probable  as  the  exciting  cause  although  in  the 
latter  instance  the  direct  evacuation  of  the  abscess  by  costo-transver- 
sectomy,  as  advocated  by  Menard,  would  seem  to  be  the  more  reason- 
able procedure.  Occasionally  the  operation  is  performed  as  a  forlorn 
hope  in  adults  suflFering  from  cystitis  and  bedsores. 

The  usual  method  in  operating  is  as  follows  :  A  long  incision  is 
made  parallel  to  and  close  by  the  side  of  the  spinous  processes.  The 
muscles  are  drawn  to  one  side,  the  spinous  processes  are  cut  through 
and  drawn  with  the  attached  muscles  to  the  opposite  side.  The  1am- 
inse  at  the  seat  of  disease  are  then  removed  with  the  cutting  forceps, 
exposing  the  dura  mater.  The  tuberculous  tissue  is  usually  found  upon 
the  front  or  lateral  surfaces  of  the  canal,  and  its  complete  removal  is 
often  impossible.  The  shock  of  the  operation  is  often  marked  so  that 
it  should  be  as  rapid  as  possible,  and  loss  of  blood  should  be  carefully 
guarded  against.  After  the  operation  the  spine  should  be  supported 
by  the  brace  or  jacket  until  the  disease  is  cured. 

In  several  instances  forcible  correction  of  the  spine  (Calot's  opera- 
tion) relieved  the  pressure  on  the  cord  and  rapid  recovery  followed. 
This  indicates  the  importance  of  assuring  over-extension  of  the  spine 
whenever  it  is  possible,  but  this  should  be  attained  by  gradual,  postural 
correction  rather  than  by  force. 

Fortunately  the  great  majority  of  cases  of  paraplegia  from  Pott's 
disease  occur  in  childhood,  and,  as  has  been  mentioned,  the  complica- 
tions of  later  life,  bedsores,  cystitis  and  the  like,  are  rarely  trouble- 
some. Such  paralysis  in  the  adult  is  more  serious  from  every  point  of 
view.  The  principles  of  treatment  are  the  same,  but  their  application 
is  more  difficult  and  the  prognosis  is  more  doubtful. 

Local  Paralysis. — In  certain  cases  the  extension  of  the  disease  may 
involve  the  nerve  roots  at  their  exit  from  the  spine.     This  may  occur 

1  Willard,  Journal  of  Nervous  and  Mental  Diseases,  May,  1897. 


DURATION  OF  TREATMENT  OF  POTT'S  DISEASE.  99 

with,' or  independently  of,  the  involvement  of  the  cord.  The  symp- 
toms ar^  those  of  neuritis  in  the  affected  nerves.  In  extremely  rare 
instances  the  pressure  on  the  cord  may  cause  hemiplegia. 

The  Duration  of  the  Treatment  of  Pott's  Disease. — The  duration 
of  the  treatment  must  depend  upon  the  extent  and  severity  of  the  disease. 
It  may  be  divided  into  two  stages  :  one  during  which  the  disease  is 
active,  when  absolute  fixation  is  indicated,  and  a  stage  of  recovery, 
during  which  supervision  is  required.  During  the  first  stage  the  de- 
structive process  may  increase  the  absolute  deformity  ;  during  the  later 
period  of  weakness  the  distortion  may  increase,  simply  because  of  the 
general  inclination  toward  deformity  and  because  of  the  weakness  of 
the  supporting  muscles. 

Tuberculosis  of  the  spine  is  slow  in  its  progress  and  recovery  is 
often  insecure.  The  course  of  the  disease  is  shortest  in  the  cervical 
region,  but  even  here  two  years  of  brace  treatment  will  probably  be 
required,  and  in  the  lower  region  double  this  time,  even  in  the  milder 
type  of  cases.  Active  treatment  should  be  continued  as  long  as  there 
is  evidence  of  disease.  The  absence  of  the  general  symptoms  of  pain  and 
weakness  is  of  little  value  in  determining  the  absolute  cure  if  braces 
have  been  employed.  Muscular  spasm  is  of  more  value,  since  it  usually 
persists  as  long  as  the  disease  is  active ;  the  presence  of  pain  on  pas- 
sive motion  or  muscular  contraction  or  abscess  would  of  course  indicate 
the  necessity  of  further  treatment. 

Direct  palpation  is  of  some  value  in  determining  the  condition  of 
the  affected  part.  During  the  progressive  stage  careful,  deep  pressure 
over  the  spinous  processes  may  show  greater  mobility  of  those  involved 
in  the  disease.  During  the  stage  of  repair  and  consolidation  the  mobil- 
ity is  replaced  by  rigidity.  The  appearance  of  the  kyphosis  has  also 
some  significance.  In  the  early  stage  of  the  disease  its  area  is  not 
clearly  defined,  but  when  consolidation  has  taken  place  the  extent  of 
the  disease  is  shown  by  the  rigid  vertebrae  which  stand  out  separated 
from  the  remainder  of  the  spine  by  a  well-marked  sulcus  which  is 
much  deeper  below  than  above  the  kyphosis. 

Even  when  the  disease  appears  to  be  cured,  oxmoval  of  support 
should  be  gradual  and  tentative  ;  the  jacket  is  replaced  by  the  corset, 
the  brace  by  a  lighter  appliance,  then  support  is  removed  at  night, 
later  for  part  of  the  day  and  at  last,  after  many  months,  it  is  discarded. 

Such  careful  supervision  must  be  continued  for  a  much  longer  time 
if  the  best  ultimate  result  is  to  be  attained,  for  as  has  been  mentioned, 
one  should  guard  against  the  secondary  distortions,  which  may  be  due 
simply  to  weakness  and  to  the  unfavorable  mechanical  conditions  in- 
duced by  the  primary  deformity.  If  curvatures  of  the  spine  are  so 
common  among  those  whose  backs  may  be  supposed  to  be  fairly  normal, 
how  much  more  likely  is  such  secondary  deformity  to  result  when  the 
back  has  been  weakened  by  disease  and  by  long  disuse  of  the  muscles. 

This  secondary  increase  of  deformity  is  not  so  much  to  be  feared 
after  the  cure  of  the  disease  in  the  lumbar  region,  because  of  the  favor- 
able attitude  of  erectness,  nor  is  it  likely  to  be  marked  after  cure  in 


100  TUBERCULOUS  DISEASE  OF  THE  SPINE. 

the  cervical  region  of  the  spine ;  but  in  disease  of  the  upper  and  mid- 
dle dorsal  region  brace  treatment  must  be  continued  long  after  the 
disease  is  cured,  and  supervision  must  be  exercised  until  after  the  period 
of  adolescence,  if  the  increase  of  deformity  is  to  be  prevented. 

Recurrence  of  Disease  and  Later  Effects  of  Deformity. — The 
disease  may  recur  after  an  interval  of  many  years  of  apparent  cure  and 
such  recurrences  are  sometimes  accompanied  by  the  formation  of  an 
abscess  or  by  paralysis. 

If  recovery  from  Pott's  disease  has  been  complete  and  if  deformity 
has  been  prevented,  the  condition  of  the  patient  is  to  all  intents  nor- 
mal, but  if  the  course  of  the  disease  has  been  prolonged  and  if  the  de- 
formity is  great,  his  condition  is  abnormal ;  he  is  unfitted  for  ordinary 
occupations,  and  comparative  comfort  is  assured  only  by  constant  care. 
Such  individuals  are  likely  to  suffer  from  neuralgic  pain  about  the 
weakened  spine  on  over-exertion  or  whenever  the  general  condition  is 
depressed  from  any  cause.  In  such  cases  the  use  of  some  form  of  light 
corset  adds  to  the  comfort  of  the  patient. 

Secondary  Deformities. — While  the  patient  is  under  treatment  for 
Pott's  disease  one  should  be  on  the  alert  to  prevent  other  deformities  that 
may  follow  the  general  weakness  and  restriction  of  normal  functions. 
One  of  these  is  the  weak  foot,  sometimes  called  weak  ankle  or  flat  foot, 
and  with  it  is  often  associated  a  moderate  degree  of  knock  knee.  This 
may  be  prevented  by  the  use  of  a  "Waukenphast  shoe,  of  which  the 
heel  and  sole  should  be  raised  one-fourth  of  an  inch  on  the  inner  side. 

Recapitulation. — Fixation  on  the  portable  frame  is  the  treatment  of 
choice  in  infancy  and  early  childhood,  without  regard  to  the  situation 
of  the  disease.  Ambulatory  treatment  is  the  treatment  of  selection  in 
later  childhood,  adolescence  and  adult  life. 

Horizontal  fixation  is  by  far  the  most  effective  treatment  of  the  local 
disease  and  deformity  ;  it  is  therefore  the  treatment  that  is  held  in  re- 
serve to  meet  emergencies,  when  symptoms  are  not  relieved,  when  de- 
formity is  advancing  and  when  complications  are  troublesome.  The 
disadvantages  of  the  treatment  are  evident  although  likely  to  be  exag- 
gerated. The  young  child  fixed  upon  the  frame  may  be  carried  about 
in  the  open  air,  but  the  older  patient  is  moved  about  with  more  diffi- 
culty and  is  likely  on  this  account  to  be  deprived  of  the  stimulation  of 
outdoor  life  as  well  as  of  exercise. 

Ambulatory  treatment  must  always  supplement  that  by  recumbency, 
and  in  the  great  majority  of  cases  it  is  the  treatment  of  necessity  and 
routine.  Its  efficiency  will  depend,  in  great  measure,  upon  the  careful 
regulation  of  the  strain  which  the  erect  posture  and  the  activity  of  the 
patient  throws  upon  the  weakened  spine. 

Of  the  relative  merits  of  the  supports  that  have  been  described  it 
may  be  stated  that  the  plaster  jacket  has  the  great  advantage  of  cheap- 
ness ;  its  use  places  the  treatment  in  the  hands  of  the  surgeon,  and  in 
the  middle  region  of  the  spine,  it  is  equal  to,  and  may  even  be  supe- 
rior to,  the  brace.  The  laced  corset  is  not  equal  as  a  support  to  the 
solid  jacket. 


FORCIBLE  CORRECTION  OF  THE  DEFORMITY.  101 

The  back  brace  has  a  wider  range  of  adaptability  than  the  jacket. 
Its  dissidvantages  are  the  original  expense,  the  difficulty  of  accurate 
adjustment  and  the  fact  that  it  can  be  removed  by  the  parents,  who  are 
inclined  to  neglect  medical  supervision,  when  the  use  of  the  apparatus 
has  become  familiar  to  them. 

The  jury  mast,  although  a  very  useful  appliance  under  certain  cir- 
cumstances, is  inferior  to  the  metallic  head  rest  when  accurate  fixation 
or  support  is  desired. 

The  complications  of  Pott's  disease,  abscess  and  paralysis,  should  be 
considered  and  treated  as  symptoms  only,  symptoms  that  may  or  may 
not  require  direct  treatment  according  to  the  indications  that  have 
been  described.  Finally  one  should  always  bear  in  mind  that  the 
final  cure  of  the  disease  depends  upon  the  increase  of  the  vital  force ; 
thus  the  importance  of  fostering  and  improving  the  general  well-being 
of  the  patient  cannot  be  too  strongly  urged. 

Forcible  Correction  of  the  Deformity  of  Pott's  Disease.  Ca- 
lot's  Operation. — Forcible  correction  of  the  deformities  of  the  spine 
was  advocated  by  several  of  the  ancient  writers,  notably  by  Hippo- 
crates and  by  Par4,  but  in  modern  times,  with  the  better  understand- 
ing of  the  pathology  of  Pott's  disease,  the  direct  deformity  that  a  pa- 
tient presented  when  coming  under  treatment  was  supposed  to  be 
irremediable,  since  it  represented  actual  destruction  of  bone. 

In  1896  this  method  of  forcible  correction  of  deformity  which  had 
been  revived  by  Chipault  several  years  before  ^  was  popularized  by 
Calot  of  Berck'sur  M^r,^  who  claimed  that  it  was  particularly  adapted 
to  the  treatment  of  the  kyphosis  of  tuberculous  disease.  Originally 
he  advocated  the  immediate  correction  of  such  deformity,  although  of 
long  standing,  even  if  chiseling  through  the  anchylosed  vertebrae  and 
removal  of  the  spinous  processes  were  required,  but  operative  treat- 
ment in  this  class  of  cases  has  now  been  practically  abandoned. 

At  the  eleventh  Congress  of  French  Surgeons  at  Paris  in  1897 
Calot  outlined  the  operation  as  follows  :  In  the  recent  cases  the  de- 
formity was  corrected  by  direct  manual  traction  and  by  pressure  on 
the  kyphosis.  The  traction  employed  was  estimated  at  60  to  160 
pounds,  the  pressure  at  30  to  80  pounds,  but  in  the  more  resistant  type 
it  was  well  to  reduce  the  deformity  gradually,  at  several  sittings.  Of 
204  patients  treated  by  this  method,  two  died  in  two  days,  and  three 
others  of  broncho-pneumonia  several  months  after  the  operation.  In 
one  case  partial  paralysis  appeared  and  in  another  an  abscess  was  ob- 
served soon  after  the  procedure. 

Since  Calot's  original  publication  hundreds  of  operations  have  been 
performed  with  results  not  differing  essentially  from  those  that  he  re- 
ported. It  has  been  demonstrated  that  the  deformity  of  Pott's  dis- 
ease, in  more  recent  cases,  can  be  partly  or  entirely  corrected  by  force 
in  one  or  more  sittings  with  but  little  danger  to  the  patient.^     If  the 

1  Travaux  de  neurologic  Clair.,  1895,  1896,  1897. 
^Archiv  prov.  de  Chir.,  February,  1897.     T.  6,  n.  2. 

"Bradford  and  Cotton  (Boston  Med.  and  Surg.  Journal,  September  20,  1900)  have 
recently  analyzed  the  literature  of  Calot' s  operation,  viz  : 


102  TUBERCULOUS  DISEASE  OF  THE  SPINE. 

disease  is  in  the  progressive  stage,  and  if  the  operation  is  undertaken 
before  adhesions  and  contractions  have  formed,  the  correction  will  be 
easy.  If  the  disease  is  in  the  stage  of  repair,  the  correction  will  ne- 
cessitate forcible  separation  of  contracted  tissues  and  the  breaking  up, 
it  may  be,  of  an  actual  anchylosis.  If  an  abscess  be  present,  whose 
coverings  are  adherent  to  the  surrounding  parts,  the  forcible  correc- 
tion may  rupture  its  walls  and  allow  the  escape  of  the  pus  into  the 
lung  or  pleural  cavity.  The  more  remote  dangers  are  abscess  or  pa- 
ralysis due  to  a  direct  extension  of  the  local  process,  or  a  general  dis- 
semination of  the  tuberculous  disease. 

If  the  spine  is  straightened  it  is  evident  that  there  must  be  an  actual 
separation  of  the  diseased  parts ;  the  spine  is,  as  it  were,  straightened 
on  the  hinge  formed  by  the  articulating  surfaces  of  the  transverse 
processes.  (Fig-  4.)  This  is  an  attitude  favorable  to  repair  since 
compression  and  attrition  can  no  longer  aggravate  the  destructive 
process.  If  paralysis  be  present,  induced  in  part  by  the  compression 
of  the  softened  tissues  at  the  seat  of  disease,  it  may  be  relieved  by  the 
correction  of  the  deformity.  This  point  was  illustrated  in  two  cases 
at  the  Hospital  for  the  Ruptured  and  Crippled  by  an  immediate  im- 
provement and  rapid  recovery  from  paraplegia  after  the  operation. 

It  must  be  borne  in  mind  however  that  the  operation  is  undertaken 
for  the  relief  of  deformity.  It  is  certain  that  the  spine  can  be  straight- 
ened and  that  it  can  be  retained  for  a  time  in  the  corrected  position, 
but  it  is  unlikely  that  the  interval  left  between  the  upper  and  lower 
segments  of  the  spine  will  be  filled  with  new  bone.  This  can  only  be 
decided  by  a  study  of  final  results  many  years  after  the  operation. 

There  is,  as  a  rule,  an  immediate  recurrence  of  a  certain  amount  of  de- 
formity because  of  the  natural  recoil  toward  the  habitual  posture,  and 
because  in  many  instances  the  straightening  of  the  spine  has  been  due  to 
an  obliteration  of  secondary  curvature  rather  than  to  actual  separation 
at  the  seat  of  disease,  and  finally  even  if  the  interval  between  the  seg- 
ments were  filled  with  calcified  tissue,  such  bone  does  not  grow  as  it  con- 
tains no  epiphyses,  consequently  this  irregularity  must  become  more  and 
more  marked  with  the  growth  of  the  child.  In  other  words  although 
the  effect  of  the  destructive  disease  on  the  spine  can  be  modified  it 
cannot  be  entirely  remedied  even  by  the  most  successful  operation. 

The  Selection  of  Cases  for  Forcible  Correction. — The  favorable 
cases  are  those  in  which  the  deformity  is  of  comparatively  short  dura- 
Six  hundred  and  thirty-nine  cases  were  performed  by  thirty-four  operators.     Time 
elapsed  varied  from  a  few  days  up  to  three  years  or  more.     Of  the  separate  detailed 
cases  in  7  more  tlian  one  year  had  elapsed  ;  in  35  more  than  six  months. 

Deaths  reported  from  all  causes,  25  ;  various  diseases,  5  ;  general  tuberculosis,  4  ; 
trauma  of  the  operation  and  chloroform,  5  ;  intercurrent  disease,  7. 

Immediate  results :  Kespiratory  embarrassment,  7  ;  pain,  6  ;  severe  shock,  3. 

Abscess  present  before  operation,  19  ;  ruptured,  4  ;  benefited  or  absorbed,  6  ;  ap- 
peared after  operation,  2. 

Paralysis  present  before  operation,  23  ;  relieved,  17  ;  not  relieved,  2  ;  made  worse, 
1.     Paralysis  appeared  after  correction  in  4. 

Direct  effect  on  deformity  in  240  cases  :  Complete  correction,  130  ;  incomplete,  94. 

Kesult  in  77  cases  :  No  relapse,  20  ;  some  relapse,  50  ;  total  relapse,  7. 


CALOT'S  OPERATION.  103' 

tion,  cases  in  which  the  adhesions  and  the  accommodative  changes  in 
the  soft  parts  are  not  sufficient  to  offer  resistance  to  correction,  and  in 
which  the  internal  organs  have  not  been  long  displaced  or  compressed. 
Well-marked  deformities  of  the  middle  and  lower  dorsal  region  are 
especially  suitable  for  the  operation. 

The  most  unfavorable  cases  are  those  of  fixed  deformity,  in  which 
repair  is  progressing  or  is  completed,  and  in  which  the  organs  and 
tissues  of  the  body  have  been  changed  in  shape  and  function  to  accom- 
modate the  new  conditions. 

As  a  rule  deformity  of  the  lumbar  and  of  the  cervical  regions  is  not 
sufficient  to  require  forcible  correction. 

The  presence  of  an  abscess  in  the  posterior  mediastinum  or  else- 
where if  it  be  in  the  active  or  progressive  stage  should  contraindicate 
the  operation.  On  the  other  hand  paralysis,  which  is  most  often  a 
complication  of  diseases  in  the  dorsal  region,  is  not  a  contraindication. 

The  Operation. — As  ordinarily  performed  the  patient  having  been 
prepared  as  for  the  application  of  a  plaster  jacket  is  ansesthetized  and  is 
then  suspended  face  downward  in  the  horizontal  position  by  five  assist- 
ants who  make  moderate  steady  traction  upon  each  extremity  and  upon 
the  head  while  the  surgeon,  standing  by  the  side  of  the  patient,  gently 
presses  downward  directly  upon  the  kyphosis,  which  in  the  favorable 
cases,  is  gradually  obliterated,  the  straightening  of  the  spine  being  ac- 
companied by  the  audible  separation  of  adhesions. 

The  force  employed,  as  stated  by  Calot,  is  traction  of  60  to  160 
pounds  and  pressure  of  from  30  to  80  pounds.  As  a  rule  the  force  is 
much  less,  and  there  is  little  danger  from  this  source.  Jones  states 
that  a  traction  force  of  nearly  600  pounds  is  required  to  dislocate  the 
neck  of  a  child  two  and  one-half  years  of  age ;  that  five  men  pulling 
in  the  manner  above  described,  with  a  force  that  soon  tires,  rarely 
exceed  a  traction  force  of  175  pounds. 

If  the  correction  is  to  be  completed  at  the  first  attempt  the  spine  is 
over-extended  and  while  it  is  held  in  this  attitude  a  plaster  jacket  is 
applied.  If  the  disease  is  of  the  middle  of  the  back,  the  head  need 
not  be  included,  but  it  is  better  to  fix  and  draw  the  shoulders  back- 
ward by  including  them  in  the  plaster.  Great  care  should  be  taken 
to  prevent  excoriation.  Very  long,  thick,  wide  pads  should  be  placed 
on  either  side  of  the  spinous  processes  ;  the  iliac  crests  and  other 
prominences  should  be  protected  and  a  so-called  dinner  pad  should  be 
inserted  below  the  sternum,  which  may,  when  removed,  allow  addi- 
tional room  for  respiration.  This  is  of  great  importance  if  the  patient 
has  not  worn  a  plaster  jacket  before  the  operation.  If  the  disease  is  of 
the  upper  dorsal  region,  the  head  must  be  included  in  the  bandage. 
Calot  suspends  the  ansesthetized  patient  as  in  the  ordinary  manner  for 
apj)lying  a  jacket ;  other  surgeons  suspend  the  patient  with  the  head 
downward  during  the  application  of  this  part  of  the  bandage,  but 
with  a  little  care  the  head  support  may  be  applied  with  the  patient  in 
the  horizontal  position. 

The  hair  should  be  cut  closely  and  protected  from  the  plaster  by  a 


104  TUBERCULOUS  DISEASE  OF  THE  SPINE. 

well-fitting  skull  cap.  The  bandage  is  then  continued  over  the  head 
and  neck  as  in  the  illustration.  (Fig.  49.)  A  strip  of  malleable 
steel,  bent  to  fit  the  occiput,  may  be  incorporated  in  the  bandage  to 
give  it  sufficient  strength. 

Many  surgeons  employ  other  supports  than  the  plaster.  One  of  the 
best  forms  of  apparatus  is  the  double  Thomas  brace  used  by  Jones. 
The  stretcher  splint  may  be  used  also. 

In  properly  selected  cases  there  is  little  shock  after  the  operation, 
but  if  the  change  in  the  contour  of  the  spine  has  been  considerable, 
respiration  may  be  somewhat  embarrassed  by  the  plaster  jacket.  In 
such  cases  it  must  be  split  through  the  front  and  separated.  In  all 
cases  it  is  well  to  cut  through  the  plaster  at  points  where  direct  pres- 
sure is  likely  to  be  exerted,  in  order  to  guard  against  excoriations. 

As  a  rule  the  operation  should  be  followed  by  prolonged  rest  on  the 
back  3  to  6  months  or  longer  to  allow  for  adaptation  to  the  new  posi- 
tion and  for  consolidation,  but  as  far  as  symptoms  are  concerned  the 
patients  may  be  up  and  about  as  usual  in  a  few  days  if  the  spine  can 
be  held  properly  by  the  plaster  jacket,  as  has  been  the  case  with  many 
of  the  patients  at  the  Hospital  for  Ruptured  and  Crippled. 

As  has  been  stated  there  is  a  marked  tendency  toward  recurrence  of 
deformity.  On  this  account  some  surgeons  advocate  wiring  the  spinous 
processes  to  one  another  as  originally  suggested  by  Hadra  and  practiced 
by  Chipault.     The  operation  is  a  simple  one,  but  its  efficacy  is  doubtful. 

In  cases  in  which  the  deformity  is  of  the  resistant  type  it  is  well  to 
divide  the  rectification  into  several  sittings  at  intervals  of  a  week  or 
more.  In  many  instances  anaesthesia  is  not  required  after  the  first 
operation ;  for  traction  and  even  the  forcible  pressure  at  the  seat  of 
disease  do  not  appear  to  cause  particular  discomfort. 

Gradual  Correction  of  Deformity. 

Corrective  force  may  be  applied  also  by  methods  that  do  not  deserve 
the  name  operation.  For  example  a  certain  amount  of  traction  and  pres- 
sure may  be  employed  with  advantage  during  the  application  of  the  plas- 
ter jacket  in  the  ordinary  manner  if  the  cases  are  properly  selected. 

But  the  most  efficacious  method  of  gradual  or  non-violent  correction 
is  that  employed  by  Goldthwait  ^  by  horizontal  traction  and  leverage. 
This  method  is  described  by  him  as  follows  : 

"  The  apparatus  which  has  been  used  consists  of  a  strong  gas-pipe 
frame,  six  feet  long  by  two  feet  wide.  Suspended  from  this  is  a  bar 
(a),  in  the  center  of  w^iich  is  a  vertical  rod  (6),  forked  at  the  top  and 
long  enough  to  reach  to  the  level  of  the  frame.  This  crossbar  is 
simply  suspended  from  the  frame  so  that  its  position  can  be  changed 
as  desired.  Below  this  is  another  crossbar  (c),  which  rests  on  the 
frame  and  can  also  be  adjusted  as  to  position.  Upon  this  latter  piece 
(c)  and  upon  the  fork  of  the  rod  (6)  rest  two  malleable  steel  bars  (c?), 
about  eighteen  inches  long.     These  rest  in  grooves  one  inch  apart,  and 

1  Trans.  Am.  Ortho.  Ass'n,  Vol.  XL,  p.  95. 


CALOT'S  OPERATION. 


105 


should  be  bent  to  partly  conform  with  the  lumbar  curve  of  the  spine, 
after  which  they  are  heavily  padded  with  felt  and  the  patient  laid 
upon  them.  The  upper  end  of  the  bars  {d)  should  just  rest  upon  the 
fork,  not  projecting  over,  and  when  the  patient  is  in  position  the  rod 
should  be  one  inch  above  the  apex  of  the  deformity.  The  buttocks 
rest  upon  the  crossbar  (c),  and  the  legs  are  supported  by  one  or  more 
heavy  webbing  straps  which  can  be  tightened  or  loosened  at  will.  No 
support  whatever  is  given  the  upper  part  of  the  body,  except  that 
the  head  is  steadied  by  the  surgeon  with  the  hand  until  a  satisfactory 
amount  of  correction  has  been  accomplished,  and  then  a  strap  similar 
to  those  used  below  gives  the  support  so  that  the  operator's  hand  is 
free.  If  traction  is  desirable,  it  can  be  applied  by  means  of  a  wind- 
lass which  is  attached  to  each  end  of  the  frame.     This  makes  it  pos- 

FiG.  58. 


The  plaster  jacket  applied  in  supine  posture  by  means  of  tlie  Metzger-Goldthwait  apparatus. 


sible  to  obtain  much  more  definite  and  steady  traction  than  would  be 
possible  with  assistants,  but  its  use  has  not  been  found  necessary  in 
the  majority  of  the  cases,  simple  over-extension  of  the  spine  accom- 
plishing the  same  results. 

When  the  maximum  over-extension  that  is  desirable  is  obtained,  the 
strap  under  the  head  is  fastened  and  the  patient  allowed  to  lie  in  this 
position  while  the  jacket  is  applied.  In  applying  this  the  iliac  crests 
should  be  generously  padded  with  heavy  felt  and  a  similar  pad  should 
be  placed  over  the  upper  part  of  the  sternum  so  that  the  jacket  can 
be  carried  high  up  to  prevent  the  upper  part  of  the  body  with  the 
shoulders  from  drooping  forward.  In  the  cases  with  disease  in  the 
upper  dorsal  region  the  jacket  should  be  moulded  about  the  anterior 
part  of  the  neck  so  that  erect  position  of  the  head  is  necessary.  The 
forked  rod  (6)  is  easily  avoided  by  a  few  figure-of-eight  turns  of  the 


106 


TUBERCULOUS  DISEASE  OF  THE  SPINE. 


bandage,  so  that  when  the  plaster  has  set  the  patient  can  easily  be 
lifted  off,  and  as  the  rod  (6)  should  be  placed  one  inch  above  the  apex 
of  the  deformity  this  weak  spot  in  the  jacket  is  not  objectionable. 

When  the  patient  is  taken  off  the  frame  the  two  rods  (d)  are  slipped 
out  from  below  leaving  the  padding  in  place. 

As  a  matter  of  experience  it  has  been  found  necessary  to  practically 
always  cut  a  small  window  over  the  point  of  greatest  deformity  as 
otherwise  when  the  body  settles  down,  as  is  inevitable,  a  slough  will 
form  even  though  a  liberal  amount  of  padding  has  been  used.  This 
procedure  is  repeated  from  time  to  time  until  the  best  possible  attitude 
has  been  obtained.  This  method  originally  devised  as  a  modification 
of  the  Calot  method  of  forcible  correction  of  deformity  is  now  em- 
ployed in  the  routine  application  of  the  plaster  jacket.  For  this  pur- 
pose Goldthwait  uses  a  portable  frame  as  shown  in  the  illustration. 

It  may  be  stated  of  forcible  correction  of  the  spine  (Calot's  opera- 


FiG.  59. 


Goldthwait's  portable  frame  for  applying  the  plaster  jacket.     (See  Fig.  46.; 


tion),  that  it  is  in  no  sense  curative ;  that  although  it  has  been  proved 
that  the  back  can  be  straightened,  in  many  instances  with  ease  and  in 
most  cases  with  but  little  danger,  yet  the  retention  of  the  spine  in  the 
corrected  position  is  difficult,  and  a  certain  immediate  recoil  toward 
deformity  is  the  rule.  Even  if  the  interval  between  the  two  seg- 
ments be  filled  with  new  bone,  the  growth  of  the  spine  at  this  point 
being  checked,  an  increase  of  the  irregularity  with  advancing  years 
may  be  expected.  In  fact,  correction  of  deformity  is  in  no  sense  a 
substitute  for  prevention.  The  ease  with  which  correction  may  be 
made  in  early  cases,  emphasizes  the  importance  of  rest  on  the  back,  in 
the  over-extended  attitude,  as  a  means  of  correcting  deformity,  in  cases 
in  which  operative  intervention  seems  to  be  contra-indicated. 

The  final  judgment  can  not  be  passed  upon  this  procedure  for  many 
years  ;  it  has  rapidly  lost  favor  during  the  past  year,  partly  because  of 
recurrence  of  deformity,  and  partly  because  experience  has  sliown  that 
the  same  degree  of  rectification  may  be  attained  by  milder  methods. 


CHAPTER    II. 


NON-TUBERCULOUS   AFFECTIONS    OF   THE   SPINE. 


Syphilis. 

This  disease,  in  the  inherited  or  in  the  later  stages  of  the  acquired 
form,  may  affect  the  bones  of  the  spine  and  cause  local  deformity  and 
symptoms  that  cannot  be  distinguished  from  those  of  Pott's  disease. 

Dia^osis. — As  compared  with  tuberculosis,  it  is  a  rare  disease  of 
the  spine.  Its  manifestations  are  likely  to  be  general  in  character,  the 
deformity  of  the  spine  being  but  one  of  many  evidences  of  disease. 

If  syphilis  were  limited  to  the  spine 
Fig.  60.  and  simulated   the  symptoms  and  the 

deformity  of  Pott's  disease,  it  would 
demand  the  same  local  treatment. 
Specific  remedies  should  always  be  ad- 
ministered when  one  has  reason  to  sus- 
pect its  presence,  as  in  the  treatment 
of  syphilitic  disease  of  other  parts. 


Malignant  Disease  of  the  Spine. 

Malignant  disease  of  the  spine  is  a 
rare  affection,  particularly  so  in  child- 
hood. Sarcoma  is  more  common  than 
carcinoma,  which,  when  it  affects  the 
spine,  is  almost  always  secondary  to  a 
primary  tumor  elsewhere,  as  of  the 
breast. 

Diagnosis. — Malignant  disease  dif- 
fers from  tuberculosis  of  the  spine  in 
that  its   symptoms  are    usually  more 
severe ;   the  pain  is  usually  persistent 
and  it  is  not   relieved  by  support  or 
recumbency,  as  is  that  of  Pott's  disease. 
The  constitutional  symptoms  are  more 
marked  and  the  steady  progress  of  the 
disease  toward  a  fatal  termination   is 
soon  apparent.     Locally,  the  angular  deformity  is  usually  slight  and  it 
may  be  absent.    Not  infrequently  the  tumor  may  be  palpated  through  the 
abdominal  wall.     Paralysis  is  a  frequent,  and  often  an  early,  symptom. 
As  has  been  stated,  carcinoma  is  almost  always  secondary,  but  sar- 


Vertical  antero-posterior  section  of 
lumbar  spine  showing  deposit  of  gumma 
in  tlie  posterior  part  of  the  third  and 
fourth  vertebrae  (after  Fourniee). 


108  NON-TUBERCULOUS  AFFECTIONS   OF  THE  SPINE. 

coma  of  the  spine  may  be  the  primary  focus  of  disease  ;  in  such  cases 
diagnosis  in  the  early  stage  is  often  impossible. 

Malignant  disease  of  the  spine  is  a  fatal  affection  and  the  treatment 
can  be  but  palliative. 

Acute  Osteomyelitis  of  the  Spine. 

Infectious  osteomyelitis  of  the  spine  is  uncommon,  but  41  cases  are 
recorded  in  literature.^ 

Symptoms. — Its  symptoms  are  similar  to  those  of  acute  infectious 
processes  elsewhere  and  are  characterized  by  sudden  onset,  with  pain, 
fever  and  constitutional  depression.  There  is  local  pain  and  tender- 
ness about  the  spine.  Abscess  quickly  forms  ;  and  paralysis,  from 
the  rapid  extension  of  the  disease  is  a  common  complication.^  The 
symptoms  due  to  pyogenic  infection  and  to  deep-seated  abscess,  are 
often  pysemic  in  character,  and  necrosis  of  the  affected  vertebral  bodies 
may  result  in  the  formation  of  large  sequestra.  The  death  rate  is 
about  50  per  cent. 

Treatment. — The  treatment  consists  in  the  immediate  evacuation 
and  drainage  of  the  abscess,  the  removal  of  the  necrosed  bone  if  pos- 
sible, and  in  supporting  the  spine  during  the  subsequent  stage  of  weak- 
ness. 

A  more  localized  and  more  chronic  form  of  osteomyelitis  may  oc- 
cur, but  it  is  practically  impossible  to  distinguish  its  symptoms  from 
those  of  tuberculous  disease. 

Actinomycosis  of  the  Spine. 

Actinomycosis  of  the  spine  is  an  extremely  rare  disease  and  need 
only  be  mentioned  as  a  possibility.  Its  diagnosis  may  be  made  by 
the  microscopic  examination  of  the  discharge  from  the  sinuses  that  al- 
most always  form  early  in  the  course  of  the  disease. 

Injury  of  the  Spine. 

Severe  sprains  or  fractures  may  simulate  disease  very  closely  and  in 
some  instances,  particularly  injurs^  of  the  cervical  region,  diagnosis  is 
practically  impossible  until  after  treatment  by  support  and  fixation 
has  been  applied ;  when,  as  a  rule,  if  disease  be  absent,  the  symptoms, 
even  though  of  long  standing,  quickly  subside. 

Fracture  of  the  spine  in  the  middle  region  may  result  in  angular 
deformity,  and  when  proper  support  has  been  neglected,  symptoms  of 
pain  and  weakness,  similar  to  those  of  Pott's  disease,  may  persist  in- 
definitely. 

Sudden  forcible  compression  of  one  or  more  of  the  vertebral  bodies 
without  displacement  and  without  severe  immediate  symptoms,  other 
than  the  slight  deformity,  may  be  the  result  of  injury,  especially  falls 

iHahn,  Beitni^e  zur  klin.  Chir.,  Ed.  XXV.,  H.  1,  1899. 
2Muller,  Deutsche  Zeits.  fur  Chir.,  Bd.  41. 


THE  BHACHITIC  SPINE. 


109 


from  a  height.  These  cases  are  not  uncommon  and  are  usually  mis- 
taken for  Pott's  disease. 

Diagnosis. — The  diagnosis  should  be  made  clear  by  the  history. 

Treatment. — In  all  such  cases,  and  whenever  weakness  of  the 
spine  persists,  and  when  motion  causes  pain,  a  support  should  be  ap- 
plied. Fracture  of  the  spine  should  be  treated  as  is  fracture  else- 
where, by  reposition  of  the  fragments,  if  possible  or  practicable,  and 
by  support,  until  the  integrity  of  the  parts  has  been  reestablished. 


Traumatic  Spondylitis. 

Kummell  ^  has  described  a  form  of  rarefying  ostitis  of  the  spine  of 
non-tuberculous  origin,  apparently  caused  by  injury.     It  is  character- 
ized by  symptoms  of  pain  and  weakness  referred  to  the  back,  and  by 
pronounced    rounded    ky- 
phosis of  the  dorsal  region.  Fig.  61. 
Motor  disturbances  of  the 
lower  extremities  are  fre- 
quent.    The    treatment  is 
similar   to    that    of  Pott's 
disease.     The  nature  of  the 
affection,  if  it  be  a  distinct 
variety  of  disease,  is  doubt- 
ful. 

The  Rhachitic  Spine. 

The  rhachitic  spine  has 
been  described  in  the  con- 
sideration of  the  diiferential 
diagnosis  of  Pott's  disease 
(p.  45).  It  most  often  de- 
velops during  the  first  or 
second  year  of  life,  in  child- 
ren who  sit  the  greater  part 
of  the  time.  It  is,  in  fact, 
simply  an  exaggeration  of 
the  contour  which  is  nor- 
mal in  the  sitting  posture  ; 
the  typical  rhachitic  ky- 
phosis is  thus  a  rounded 
projection  of  the  lower  re- 
gion of  the  spine,  which  is 
more  or  less  rigid  according 

to  its  duration.  If  the  deformity  is  extreme,  there  is  often  a  compensa- 
tory backward  inclination  of  the  head  which  may  be  exaggerated  by 
contraction  of  the  posterior  group  of  muscles,  "  cervical  opisthotonos." 

'  Kummel],  Deutsche  med.  Wochens.,  1895,  X.  11. 


Ehachitic  kyphosis. 


110  NON-TUBERCULOUS  AFFECTIONS  OF  THE  SPINE. 

Treatment. — Aside  from  the  constitutional  treatment  of  the  rhachitic 
condition,  and  from  the  measures  that  should  be  employed  to  improve 
the  nutrition  of  the  muscles  in  general,  the  indications  are  to  overcome 
the  rigidity  and  the  limitation  of  motion  in  the  spine  ;  to  support  it,  if 
necessary,  during  the  stage  of  weakness  ;  and  to  remove,  if  possible, 
the  predisposing  causes. 

The  correction  of  the  deformity  may  be  accomplished  by  massage, 
and  by  direct  manipulation  of  the  spine.  The  child  is  placed,  face 
downward,  on  a  table ;  one  hand  is  applied  over  the  projection,  and 
with  the  other  the  legs  are  raised  to  throw  the  spine  into  a  position  of 
over-extension.  This  stretching  is  performed  slowly  and  carefully 
over  and  over  again  at  morning  and  night,  and  the  manipulation  is 
followed  by  thorough  massage  of  the  muscles.  If  the  deformity  is 
marked  and  if  the  general  rhachitic  process  is  still  active,  the  infant 
may  be  kept  for  several  months  in  the  recumbent  posture,  on  the  frame 
or  similar  support. 

In  older  subjects  some  form  of  light  back  brace  may  be  sufficient 
in  connection  with  the  massage,  and  systematic  correction  of  the  de- 
formity. 

The  Natural  Cure. — It  may  be  stated  that  the  rhachitic  spine  is  to  a 
certain  extent  corrected  when  the  erect  posture  is  assumed,  by  the  in- 
clination of  the  pelvis  and  accompanying  lordosis.  This  natural  cure 
is  however  often  rather  a  distribution  of  deformity  than  a  cure,  for  the 
upper  part  of  the  projection  may  remain  as  an  exaggeration  of  the 
normal  dorsal  kyphosis  balanced  by  an  exaggerated  lordosis,  "  the 
rhachitic  attitude"  And  in  other  instances  the  persistence  of  the 
lumbar  kyphosis  may  induce  a  compensatory  flattening  of  the  normal 
dorsal  kyphosis.  Thus  rhachitis  may  cause  the  so-called /a^  hack,  as 
well. 

PAINFUL    AFFECTIONS    OF     THE     SPINE     NOT    ATTENDED     BY 
ANGULAR    DEFORMITY. 

Infectious   Disease    of  the    Coverings    or    Articulations   of  the 
Spine.     "  The  Typhoid  Spine."     (Gibney.) 

During  the  course  of,  or  during  convalescence  from,  typhoid  fever, 
and  occasionally  after  apparent  recovery  from  the  disease,  symptoms 
of  pain,  weakness  and  stiifness  of  the  back  may  appear.  These  are 
caused  apparently  by  secondary  infection  of  the  fibrous  coverings  and 
attachments  of  the  spine,  similar  to  the  more  common,  but  more  severe, 
forms  of  periostitis  of  the  tibia  or  other  bones,  from  the  same  cause. 
There  is  usually  pain  on  motion  and  pain  on  pressure  over  the  afPected 
vertebrae. 

Diagnosis. — The  diagnosis  is  usually  made  clear  by  the  history  of 
the  disease  of  which  it  is  a  complication. 

Treatment. — The  treatment  should  be  symptomatic.  During  the 
active  stage,  if  pain  is  severe,  the  patient  should  be  kept  in  the  recum- 
bent position  and  opiates  may  be  administered  if  necessary.     Locally, 


SPONDYLITIS  DEFORMANS. 


Ill 


Fig.  62. 


the  application  of  the  Paquelin  cautery  is  of  service.  As  soon  as  is 
practicable  a  back  brace  should  be  applied,  which  may  be  worn  until 
the  symptoms  have  subsided.  Recovery  may  be  predicted  although  a 
certain  amount  of  restriction  of  motion  may  persist. 

Symptoms  resembling  these  may  follow  other  forms  of  contagious 
disease,  notably  scarlet  fever,  but  as  a  rule  they  are  much  less  persis- 
tent and  severe. 

Gonorrhceal  Rheumatism  of  the  Spine. 

"Gonorrhoeal  rheumatism"  of  the  spine  is  rare.     Its  symptoms  resem- 
ble those  of  the  typhoid  spine.     Anchylosis  is,  however,  more  common 
as  a  result ;  in  fact  infection  of 
this  character  is  supposed  to  be 
one  of  the  causes  of  spondylitis 
deformans. 

Locally  massage,  and  support 
to  prevent  deformity,  are  indi- 
cated. 

Arthritis  of  the  Spine. 

The  smaller  joints  of  the 
occipito-axoid  region  are  some- 
times affected  by  what  appears 
to  be  a  form  of  acute  infectious 
arthritis  similar  in  symptoms  to 
acute  rheumatism  of  this  region 
but  strictly  localized.  It  may 
follow  tonsilitis,  diphtheria  or 
other  contagious  disease.  It 
may  be  distinguished  from  tu- 
berculous disease  by  its  acute 
onset  and  from  acute  torticollis 
by  the  fact  that  all  motions  are 
restricted. 

Treatment. — The  treatment 
consists  in  support  during  the 
acute  stage  followed  by  massage 
and  manipulation  to  overcome 

the    subsequent  stiffness.  spondylitis  deformans.     (GOLDTHWAIT.) 


Spondylitis  Deformans. 

Synonyms. — Osteo-arthritis  of  the  Spine  —  Rheumatism  of  the 
Spine — Spondylose  Rhizomelique — Stiffness  of  the  Vertebral  Column. 

Spondylitis  deformans  is  an  inflammatory  aifection  of  the  spine  ter- 
minating in  ankylosis  and  deformity. 

Pathology. — The  disease  is  apparently  a  chronic  inflammation 
which  aifects  primarily  the  ligaments  and  the  periosteal  coverings  of 


112 


NON-TUBERCULOUS  AFFECTIONS  OF  THE  SPINE. 


Fig.  63. 


the  spine^  a  form  of  ossifyiDg  periostitis  which  binds  the  vertebrae  firmly 
to  one  another.  (Fig.  62.)  It  may  begin  on  the  lateral  or  on  the  anterior 
aspect  of  the  spine ;  it  may  be  limited  to  a  particular  region,  but  in 
most  instances  it  involves  the  entire  spine  and  often  the  articulations 
of  the  ribs  as  well.  The  intervertebral  discs  atrophy,  but  in  some  in- 
stances the  margins  of  the  cartilages 
proliferate  and  become  ossified  in  a 
manner  characteristic  of  osteo-arthri- 
tis  of  the  joints. 

Under  the  general  term  of  spondy- 
litis deformans  are  included,  in  all 
probability,  several  varieties  of  dis- 
ease ;  for  example  : 

1 .  The  anchylosis  of  the  spine  may 
be  simply  a  part  of  a  general  rheu- 
matoid arthritis  —  Rheumatoid  Ar- 
thritis of  the  Spine. 

2.  The  spine  may  be  involved  to- 
gether with  one  or  more  of  the  ad- 
jacent joints  which  show  the  char- 
acteristic symptoms  of  the  hyper- 
trophic form  of  rheumatoid  arthritis. 
Osteo-arthritis  of  the  Spine.  This 
form  has  been  designated  by  Marie 
as  Spondylose  Rhizom6lique,  spon- 
dylos-spine,  rhizo-root,  melos-ex- 
tremity,  signifying  a  disease  of  the 
spine  together  with  the  adjoining 
"  root "  joints.^ 

3.  The  disease  may  be  limited  to 
the  spine  and  in  such  cases  it  ap- 
pears to  be  entirely  distinct  from 
rheumatoid  arthritis.  It  may  follow 
acute  rheumatism,  it  may  be  induced 
apparently  by  gonorrhoea,  or  by 
other  forms  of  infection.  It  may 
begin    acutely     like     inflammatory 

rheumatism  or  it  may  be  chronic  in  character  and  progress  slowly.^ 
Symptoms. — In  the  ordinary  cases  there  is  usually  an  acute  onset 
from  which  the  patient  dates  the  beginning  of  his  trouble,  followed  by 
a  gradually  increasing  stiffness  of  the  spine  and  accompanying  de- 
formity. The  patient  complains  of  stiffness,  weakness,  pain  in  the 
loins  and  of  pain  radiating  forward  along  the  ribs.  Sometimes  symp- 
toms of  Aveakness  in  the  limbs,  headache,  nervousness  and  the  like  are 
present,  symptoms  that  may  be  explained  in  part  by  the  inflammatory 


Spondylitis  deformaus  in  a  child. 


'Marie,  Eevue  de  M^d.,  Vol.  18,  1898. 
2  Bechterew,  Neurol.  Centb.,  Vol.  II.,  p.  426. 
20,  1897. 


Senator,  Berlin,  klin.  Woclien.,  Nov. 


SPOND  Y LITIS  DEFOB  MANS. 


113 


process  and  by  implication  of  the  nerve  roots  and  in  part  by  an  accom- 
panying; neurasthenia.  The  direct  symptoms  are  increased  by  jars 
which  are  exaggerated  by  the  inelasticity  of  the  spine.  The  disease  is 
usually  progressive  and  terminates  finally  in  complete  rigidity  of  the 
spine  which  is  bent  into  a  long  kyphosis  most  marked  in  the  upper 
dorsal  region,  the  lumbar  lordosis  being  obliterated  in  many  instances. 

When  the  disease  is  limited  to  the  spine  and  larger  joints,  the  occi- 
pito-axoid  articulations  are  not  usually  involved. 

The  types  of  the  disease  may  be 
illustrated  by  a  brief  description  of  Fig.  64. 

four  cases  recently  under  observa- 
tion. 

Case  1.  Chronic  Rheumatoid 
Arthritis  of  the  Spine. — In  this 
case,  in  a  boy  ten  years  of  age,  there 
was  characteristic  general  rheuma- 
toid arthritis  that  involved  nearly 
every  joint  of  the  body.  The  entire 
spine,  even  including  the  occipito- 
axoid  joints,  was  rigid  and  the  head 
was  fixed  in  an  attitude  of  extreme 
torticollis. 

Case  2.  Osteo-arthritis  of  the 
Spine.  —  "  Spondylose  Rhizome- 
lique."  A  man  forty-six  years  of 
age,  after  repeated  attacks  of  so- 
called  rheumatism  involving  the 
larger  joints,  became  gradually  dis- 
abled because  of  pain  and  stiffness 
of  the  back  and  because  of  his 
inability  to  stand  erect.  In  this 
case  there  was  complete  anchylosis 
of  the  spine  except  of  the  small 
joints  of  the  cervical  region,  and 
in  addition  the  right  thigh  was 
flexed  upon  the  body  at  such  an 
angle  that  the  patient  could  walk 
only  with  an  exaggerated  stoop. 
The  joints  of  the  feet  were  slightly 
involved  also.  No  cause  other 
than  exposure  to  cold  and  dampness 

could  be  assigned.  The  'symptoms  were  of  two  years'  duration,  periods 
of  comfort  alternating  with  disabling  attacks  of  "  rheumatism." 

Case  3.  Spondylitis  Deformans. — The  spine  of  this  patient,  a  man 
forty-six  years  of  age,  was  absolutely  anchylosed  in  the  characteristic 
position.  The  occipito-axoid  joints  were  not  involved.  Fourteen 
years  before,  he  had  suffered  from  a  severe  and  prolonged  attack  of  in- 


Extreme  posterior  curvature  of  the  spine 
in  adolescence,  showing  retraction  of  the  ab- 
domen. 


114  NON-TUBERCULOUS  AFFECTIONS  OF  THE  SPINE. 

flammatory  rheumatism,  affecting  nearly  every  joint,  but  not  the  spine, 
and  during  a  succeeding  period  of  nine'  years  he  had  been  disabled 
several  times  from  the  same  cause.  Each  illness  was  coincident  with 
gonorrhoea.  Five  years  before  examination  the  rheumatism  had  in- 
volved the  spine  and  since  then  he  had  suffered  from  persistent  "  lum- 
bago." Gradually  the  stiffness  of  the  spine  had  increased,  but  during 
this  time  he  had  been  free  from  gonorrhoea  and  from  rheumatism  as 
well.  The  joints  were  normal  in  appearance  and  function.  This  pa- 
tient suffers  principally  from  nervousness  and  irritability ;  he  is  easily 
startled,  he  feels  as  if  his  forehead  were  clasped  by  a  tight  band. 
His  direct  symptoms  are  pain  in  the  loins  and  pain  radiating  under 
the  shoulder  blades,  increased  by  walking  or  by  jars.  His  equilibrium 
is  disturbed  by  the  forward  projection  of  the  head  and  by  the  obliter- 
ation of  the  normal  lordosis,  so  that  he  feels  himself  constantly  inclined 
to  fall  forward,  whether  he  is  sitting  or  standing. 

Case  4. — In  another  case  very  similar  to  this,  in  a  man  thirty  years 
of  age,  the  spine  had  become  rigid  in  a  few  months.  The  patient 
ascribed  the  disease  to  sleeping  out  of  doors.  There  was  in  this  case 
coincident  disease  of  the  lungs. 

Treatment. — The  local  treatment  is  symptomatic.  The  application 
of  cautery  adds  to  the  patient's  comfort,  and  self  suspension  at  inter- 
vals may  relieve  the  dragging  sensation  in  the  muscles.  Rubber  heels 
are  of  service  in  lessening  the  jar.  A  brace  may  be  applied  if  the  pain  is 
aggravated  by  motion  ;  it  may  also  serve  together  with  the  avoidance 
of  predisposing  attitudes  to  prevent  extreme  deformity  of  the  spine. 

Kyphosis  of  Adolescents. — A  form  of  extreme  kyphosis  accompanied 
by  stiffness  and  discomfort  is  sometimes  seen.  It  appears  to  be  a  static 
deformity  induced  by  over-work,  in  rapidly  growing  adolescents.  It 
can  hardly  be  classified  with  spondylitis  deformans,  although  there  may 
be  some  difficulty  in  distinguishing  between  the  two.     (Fig.  61.) 

Osteitis  Deformans. 

Synonym. — Paget's  Disease. 

Osteitis  deformans  is  a  general  disease  characterized  by  hypertrophy 
and  softening  of  the  bones.  The  deformity  of  the  spine  is  similar  to 
that  of  rheumatoid  arthritis,  but  the  rigidity  of  the  spine  is  not  as  ex- 
treme.    The  disease  is  described  elsewhere. 


PAINFUL    AFFECTIONS    OF    THE    SPINE    NOT    ATTENDED 
BY    RIGIDITY. 

The  Neurotic  Spine, 

The  "  neurotic"  spine  is  much  more  common  in  adolescence  and  in 
adult  life  than  in  childhood,  and  it  is  much  more  often  observed  in 
females  than  in  males.  The  subjects  are  usually  of  a  nervous  or  neu- 
rasthenic type,  although  in  certain  instances  the  symptoms  appear  to 
be  the  direct  result  of  injury. 


THE  HYSTERICAL  SPINE. 


115 


Fig.  65. 


Symptoms. — The  patient  usually  complains  of  a  dull  pain  in  the 
back  of  the  neck,  or  in  the  lumbar  or  sacral  region,  of  a  constant 
tired  feeling,  and,  not  infrequently,  of  sharp  neuralgic  pain  localized 
about  a  certain  point'  in  the  spine,  often  the  vertebra  prominens.  The 
contour  of  the  spine  may  be  normal,  but  most  often  there  is  a  well- 
marked  tendency  toward  a  forward  droop,  the  curve  of  weakness.  (Fig. 
65.)  One  of  the  characteristics  of  the  neurotic  spine  is  the  extreme  heal 
tenderness,  or  hypersesthesia,  of  the  skin  at  certain  points  along  the 
spinous  processes.  Thus  if  one  passes  the  finger  gently  along  the  spine, 
the  patient  will  often  shrink  or  cry  out,  because  of  the  pain.  As  a 
rule  there  is  no  limitation  of 
motion  or  muscular  spasm. 
The  pain  is  local,  not  re- 
ferred to  the  terminations  of 
the  nerves ;  in  fact  the  symp- 
toms are,  in  great  part, 
subjective  and  irregular  in 
character  as  contrasted  with 
those  of  Pott's  disease  which 
are  objective  and  well  de- 
fined. 

Treatment. — The  treat- 
ment of  the  neurotic  spine 
must  be  general  in  character 
as  indicated  by  the  condition 
of  the  patient.  Locally,  a 
light  back  brace  or  a  long 
steel  corset  reinforced  with 
steel  bands,  combined  with 
the  application  of  the  cau- 
tery, is  useful  as  a  prelimi- 
nary treatment.  Later,  mas- 
sage and  exercises  may  be 
employed.  Complete  recov- 
ery is  usually  long  delayed. 

The  Hysterical  Spine. 

The  hysterical  spine  is 
considered  usually  as  sy- 
nonymous with  the  neurotic 
spine,  but  as  there  are  many 

individuals  who  suffer  from  sensitive  spines  who  are  not  hysterical,  it 
would  seem  proper  to  limit  the  latter  term  to  the  hysterical  class. 

Symptoms. — The  symptoms  do  not  differ  particularly  from  those  of 
the  neurotic  spine  except  that  in  certain  instances  actual  deformity 
may  be  present ;  usually  exaggerated  lateral  distortion,  most  marked 
in  the  lumbar  region.     Such  cases  are  often  supposed  to  be  the  effe  ct 


The  neurotic  spine.      Characteristic  attitude. 


116 


NON-TVBERCULOUS  AFFECTIONS  OF  THE  SPINE. 


of  injury,  particularly  of  blows  upon  the  back,  but  except  as  a  pos- 
sible cause  of  the  appearance  of  a  particular  manifestation  of  the  men- 
tal condition,  injury  could  not  explain  the  symptoms  or  the  deformity. 
Treatment. — The  local  treatment  is  similar  to  that  of  the  neurotic 


spii 


Pain  in  the  Lower  Part  of  the  Back. 


Pain  in  the  lumbar  region  of  the  character  of  tire,  weakness,  or  even 
of  more  extreme  discomfort,  is  sometimes  an  accompaniment  of  dis- 
ease or  displacement  of  the  pelvic  or  abdominal  organs.  Pain  in  this 
region  is  also  a  common  symptom  among  overworked  women.  It  is 
particularly  troublesome  when  for  any  reason  the  lumbar  lordosis  is 
exaggerated  temporarily,  as  during  pregnancy,  or  permanently  as  a 
compensatory  deformity  for  dorsal  Pott's  disease,  or  because  of  flexion 
of  the  thigh  after  hip  disease. 

As  a  result  of  strain  or  injury  symptoms  of  pain  and  weakness  in 
the  lumbar  region  increased  by  sudden  motions  or  over-exertion,  may 
be  persistent  and  disabling.  Such  cases  are  often  classed  as  chronic 
lumbago  and  are  probably  the  result  of  strain  of  the  ligaments  or  deep 
muscles  of  the  spine  aggravated  it  may  be,  in  certain  instances,  by 
rheumatism  or  other  general  affection  of  like  character. 

The  treatment  must  be  primarily  directed  to  the  condition  of  which 
the  pain  is  a  symptom. 

When  motion  causes  pain  and  when  the  symptoms  are  persistent, 
as  in  the  lumbago  type  of  cases,  support  in  the  form  of  a  back  brace,  is 
indicated,  the  Knight  brace  or  plaster  corset  being  convenient  forms. 

During  the  more  acute  stage  the  ap- 
FiG.  66.  plication  of  the  cautery  and  the  sup- 

port of  intersecting  strips  of  adhesive 
plaster,  covering  a  wide  area,  will  often 
relieve  the  pain.  Later,  massage,  elec- 
tricity and  the  like  may  be  of  service. 

Spondylolisthesis. 


Spondylolisthesis  is  a  deformity  in 
which  the  body  of  one  of  the  lower  lum- 
bar vertebrae,  most  often  the  fifth, is  dis- 
placed forward  and  downward.  (Fig. 
QQ.)  The  displacement  is  peculiar  in 
that  the  spinous  process  may  remain  in 
its  normal  position,  while  the  laminae 
become  elongated  or  separated  from  the 
displaced  body.  The  condition  was 
first  described  by  Killian  in  1854  and  it  was  very  thoroughly  inves- 
tigated by  Neugebauer  '  in  1890. 

The  supposed  causes  are  congenital  malformation,  injury  and  pos- 

'  Lovett,  Trans.  Am.  Ortho.  Ass'n,  Vol.  X.,  p.  22. 


Small  pelvis  of  Prague  (median  section). 
Instance  of  slight  forward  displacement  of 
fifth  lumbar  vertebra.     (Neugebauer.  ) 


SACRO-ILIAC  DISEASE.  117 

sibly  disease  of  the  lumbo-sacral  articulation.  Lane  states  that  slighter 
degrees  of  the  deformity  are  often  observed  among  laborers.  The 
effect  of  the  displacement  is  to  exaggerate  the  lumbar  lordosis  and  to 
increase  the  prominence  of  the  sacrum  and  of  the  iliac  crests.  The 
deformity  is  most  often  seen  in  women  in  whom  it  causes,  in  many 
instances,  no  particular  symptoms,  in  fact  its  chief  interest  lies  in  its 
effect  upon  child-birth.  As  a  rule,  however,  as  has  been  stated  in  the 
preceding  section,  an  increase  of  the  lumbar  lordosis  is  usually  at- 
tended by  a  certain  degree  of  discomfort  and  pain. 

Lovett  ^  has  described  a  case  in  which  the  deformity  was  the  result 
of  direct  injury.  The  patient,  a  young  man,  was  successfully  treated 
by  a  plaster  jacket.  Such  cases,  and  those  in  which  displacement  is 
the  result  of  disease,  may  require  orthopaedic  treatment  by  braces  or 
other  support,  for  the  relief  of  pain  and  for  the  prevention  of  further 
defo'rmity. 

Deformity   Secondary  to   Sciatica. 

Synonym. — Sciatic  Scoliosis. 

Severe  sciatica  often  induces  a  change  in  the  attitude  and  contour 
of  the  spine  that  may  become  a  permanent  deformity  if  its  cause  per- 
sists. As  a  rule  the  patient  habitually  inclines  the  body  away  from 
the  painful  part,  in  order  to  relieve  the  leg  from  weight,  and  bends 
the  body  slightly  forward  and  abducts  the  limb  to  relax  the  tension  on 
the  sensitive  nerve  or  plexus  of  nerves.  Thus  the  pelvis  on  the  affected 
side  projects,  there  is  a  lateral  lumbar  convexity  toward  the  opposite 
side,  and  often  the  normal  lumbar  lordosis  is  lessened  or  lost  so  that  the 
final  result  may  be  a  persistent  lateral  curvature,  together  with  a  change 
in  the  antero-posterior  contour  of  the  spine.  (Fig.  66.)  If  the  sci- 
atica is  a  symptom  of  a  more  widespread  neuritis,  muscular  weakness 
and  muscular  spasm  may  cause  variations  in  the  typical  attitude,  but 
this  is  unusual. 

It  must  be  borne  in  mind  that  disease  of  the  lumbar  spine,  or  of  the 
pelvic  bones  or  joints,  or  disease  of  the  adjacent  organs  or  parts  may 
set  up  sciatica  ;  thus  the  cause  of  the  pain  should  be  carefully  sought  for. 

Aside  from  the  direct  treatment  of  sciatica,  support  for  the  spine, 
preferably  a  light  corset,  may  be  indicated,  if  motion  aggravates  the 
pain  or  if  the  deformity  persists. 

Neuritis  in  other  regions  of  the  spine  may  cause  symptoms  of  re- 
flected pain  and  local  sensitiveness.  These  symptoms  are  increased 
by  motion,  and  a  certain  amount  of  local  deformity,  similar  in  charac- 
ter to  that  due  to  sciatica,  may  be  present. 

The  treatment  is  similar  to  that  indicated  in  the  former  affection. 

Sacro-Iliac  Disease. 

Tuberculous  disease  of  the  sacro-iliac  articulation  is  a  rare  affection, 
and  extremely  so  in  childhood. 

Symptoms. — The  symptoms  are  pain,  weakness,  limp  and  change 
in  attitude.  The  pain  is  referred  to  the  side  of  the  pelvis  or  radi- 
1  Trans.  Am.  Ortho.  Ass'n,  Vol.  X. 


118"^ 


NON-TUBERCULOUS  AFFECTIONS  OF  THE  SPINE. 


Fig.  67. 


ates  over  the  buttock  or  thigh.  It  is  increased  by  jars,  by  turning 
the  body  suddenly,  sometimes  by  coughing  or  laughing ;  and  a  pe- 
culiar feeling  of  insecurity  and  weakness  is  sometimes  complained 
of.     As  a  rule  the  body  is  inclined  toward  the  sound  limb,  thus  the 

pelvis  is  lowered  on  the  aifected  side 
and  the  leg  seems  longer  than  its  fellow. 
In  the  early  stage  of  the  disease  there  is 
no  deformity  of  the  limb,  but  if  a  pelvic 
abscess  forms,  the  thigh  may  become 
flexed.  Locally,  there  may  be  sensitive- 
ness to  pressure  on  the  articulation,  and 
swelling  in  the  neighborhood  of  the  dis- 
ease, although  this  is  usually  a  late  symp- 
tom. Pain  is  induced  by  lateral  pres- 
sure on  the  pelvis  or  by  any  manipula- 
tion that  disturbs  the  articulation. 

Abscess  finally  forms  in  the  majority 
of  cases.  It  may  be  extra-  or  intra- 
pelvic.  The  intra-pelvic  abscess  may 
present  above  the  crest  of  the  ilium,  or 
the  pus  may  pass  through  the  sciatic 
notch,  or  appear  in  the  ischio-rectal 
fossa,  or  break  into  the  rectum. 

Diagnosis. — Sacro-iliac  disease  may 
be  mistaken  for  SCIATICA,  or  for  disease 
of  the  HIP  OR  SPINE.  The  freedom  of 
motion  and  the  absence  of  muscular 
spasm  when  the  pelvis  is  fixed,  if  the 
examination  is  carefully  conducted, 
should  exclude  both  the  one  and  the 
other,  although  the  pain  on  lateral 
pressure  which  is  described  as  the  most 
characteristic  symptom,  may  be  simu- 
lated closely  by  primary  acetabular  dis- 
ease. The  attitude  is  similar  to  that  of 
sciatica,  but  the  symptoms  of  local  sen- 
sitiveness to  jars  and  to  manipulation 
are  much  more  marked. 

Prognosis. — According  to  the  statis- 
tics the  prognosis  is  very  unfavorable, 
probably  because  the  majority  of  the 
reported  cases  were  in  adults  and  were 
complicated  by  infected  and  burrowing 
abscesses,  which  constitute  the  chief  danger  of  this  form  of  tuberculous 
disease. 

Treatment. — The  local  treatment  consists  in  protecting  the  diseased 
parts  from  injury,  and  in  the  radical  removal  of  the  disease  if  it  has 
reached  the  stae-e  of  abscess  formation. 


Deformity  caused  by  persistent 
sciatica  of  the  right  side.  This  atti- 
tude is  similar  to  that  symptomiatic  of 
sacro-iliac  disease. 


SACBO-ILIAC  DISEASE.  119 

In  the  ambulatory  treatment,  a  plaster  spica  bandage,  or  a  double 
Thomas  hip  brace  combined  with  the  use  of  crutches  may  be  indicated, 
but  in  most  instances  a  broad,  strong  pelvic  girdle  which  may  be 
drawn  tightly  about  the  pelvis,  will  be  most  efficient.  If  motion  of 
the  spine  causes  discomfort,  this  girdle  may  be  reinforced  by  some 
from  of  spinal  brace.  If  the  disease  is  progressive  rest  in  bed  will  be 
necessary. 

When  abscess  is  present  radical  treatment  is,  as  a  rule,  indicated. 
The  articulation  should  be  freely  exposed  and  the  diseased  bone  should 
be  entirely  removed,  if  possible.  Intra-pelvic  abscess  should  be 
drained  through  a  direct  communication,  in  order  to  check,  if  possible, 
the  tendency  toward  burrowing. 

Injury  of  the  Sacro-iliac  Articulation. — In  some  instances 
the  symptoms  of  sacro-iliac  disease  are  apparently  due  directly  to  falls 
on  the  buttock  or  pelvis.  In  such  cases  the  symptoms  are  readily  re- 
lieved by  support,  and  the  presence  of  actual  disease  seems  to  be  doubt- 
ful. 


CHAPTER    III. 


LATERAL  CURVATURE  OF  THE  SPINE. 


Fig. 


Synonyms. — Rotary  Lateral  Curvature — Scoliosis. 
Lateral  curvature  of  the  spine  is  an  habitual  or  fixed  deformity  in 
which  the  spine  is  deviated  in  whole  or  part  to  one  or  the  other  side  of 
the  median  line. 

By  limiting  the  term  to  habitual  deformity  one  excludes  simple 
postural  inclination  of  the  spine.  For  example,  if  one  leg  were  con- 
siderably shorter  than  the  other  the  pelvis  would  be  tilted  downward 

on  the  short  side  and  there  would  be 
a  compensatory  curvature  of  the  spine 
in  the  erect  attitude,  which  would  dis- 
appear in  the  sitting  posture.  This 
accommodative  curvature,  and  those 
of  similar  origin,  would  not  be  desig- 
nated as  lateral  curvature  of  the  spine. 
In  persistent  lateral  curvature  the 
anterior  part  of  the  column,  made  up 
of  the  bodies  of  the  vertebrae  that 
support  the  weight,  is  more  distorted 
than  are  the  spinous  processes,  be- 
cause lateral  distortion  is  always  ac- 
companied by  a  certain  degree  of 
twisting  or  rotation  of  the  vertebral 
bodies.  This  rotation  is  in  the  direc- 
tion of  the  convexity  of  the  curve, 
and  as  the  bodies  rotate  the  spinous 
processes  are  carried  in  the  reverse 
direction.  Thus  it  is  that  well- 
marked  rotation  may  be  present,  al- 
though there  may  be  comparatively 
little  lateral  deviation  of  the  line  of 
the  spinous  processes. 

In  the  physiological  movements  of 
the  spine,  simple,  direct  lateral  mo- 
tion, that  is,  motion  allowed  by  the 
small  joints  of  the  spine  and  by  the 
lateral  compression  of  the  interverte- 
bral discs,  is  very  limited ;    the  larger  movements   must  be  accom- 
panied by  rotation  of  the  vertebral  bodies  by  which  this  continuous 
or  solid  part  of  the  column  is,  as  it  were,  forced  from  the  shortened  to- 


Physiological  rotation  aceompaDying 
flexion  and  lateral  inclination  of  the  trunk 
in  the  normal  subject. 


SYNONYMS. 


121 


ward  the  lengthened  side.  (Fig.  68.)  When  for  example,  one  flexes 
the  head  to  bring  the  ear  as  near  the  shoulder  as  is  possible  there  is 
necessarily  an  accorapanying"rotation  of  the  chin  in  the  opposite  direc- 
tion caused  by  the  twisting  of  the  bodies  of  the  cervical  vertebrae 
toward  the  convexity  of  the  curve.  Thus  torticollis,  in  which  the  neck 
is  held  in  this  attitude,  causes  often  a  fixed  rotary  lateral  curvature  of 
the  cervical  vertebrae. 

In  the  simple  accommodative  lateral  inclination  of  the  body  to  one 
side  or  the  other,  the  change  in  contour  of  the  spine  would  be  more 
noticeable  if  it  could  be  observed  from  the  front  rather  than  from  the 
back,  and  as  lateral  curvature  is  simply  a  persistent  deviation  of  the 
spine,  one  of  the  so-called  static  deformities  which  are  directly  induced 
or   exaggerated    by    superin- 
cumbent weight,  it  is  probable  Fig.  69. 
that  rotation  of  the  vertebral 
bodies  precedes,  in  most  in- 
stances, the  lateral  distortion 
that  first  attracts  attention. 

It  is  probable  also  that 
slight  rotation  may  not  cause 
at  once  an  appreciable  degree 
of  external  distortion,  and 
although  marked  lateral  cur- 
vature is  necessarily  combined 
with  rotation,  yet  it  is  possible 
that  a  slight  degree  of  direct 
lateral  deviation  may  exist  un- 
accompanied by  appreciable 
rotation.  Rotation  is  usually 
understood  to  imply  fixed  de- 
formity, while  lateral  devia- 
tion may  mean  simply  an 
habitual  posture  ;  but  it  is  far 
simpler  to  consider  the  two 
as  parts  of  one  distortion. 
The  true  and  important  dis- 
tinction is  between  habitual 
deformity,  implying  the  habit- 
ual assumption  of  an  improper 
attitude  in  which  the  accom- 
modative changes  in  structure 
have  not  advanced  sufficiently 
to  prevent  voluntary  or  pas- 
sive correction,  and  fixed  deformity  in  which  the  changes  in  the  bones 
and  other  tissues  have  made  cure  difficult  or  impossible.  The  evidence 
of  fixed  deformity  is  rotation  that  persists  after  the  lateral  deviation  has 
been  overcome.  It  persists  because  the  early  and  important  changes 
must  take  place  in  the  bodies  of  the  vertebrae  that  support  the  weight, 


Congenital  total  scoliosis.     Compare  with  Fig.  70. 


122 


LATERAL   CURVATURE  OF  THE  SPINE. 


but  there  is  no  reason  to  believe  that  habitual  rotation  as  an  accom- 
paniment of  habitual  lateral  curvature  may  not  be  corrected  if  it  be 
treated  at  the  proper  time. 

The  necessity  for  dividing  the  weight  about  the  center  of  gravity 
in  order  to  balance  the  body  in  the  upright  position  accounts  for  the 
distribution  and  effects  of  lateral  curvature.  As  the  normal  contour 
of  the  spine  is  the  necessary  result  of  static  conditions,  a  change  from 
this  normal  relation  of  one  part  necessitates  a  corresponding  change 
elsewhere.  If  there  be  a  primary  lumbar  curvature  and  rotation  to 
the  left  in  the  lower  region,  a  corresponding  lateral  deviation  and  rota- 
tion to  the  right  in  the  region  above  usually  develops,  thus  restoring 
the  balance  of  the  body.  This  explains  the  ordinary  S-shaped  or 
double  curve  of  scoliosis,  one  of  which  is  primary  and  the  other  see- 


Fro.  70. 


Congenital  total  scoliosis.    The  rotation  is  much  greater  than  the  lateral 
deviation.    Compare  with  Fig.  69. 

ondary.  These  curves  may  divide  the  spine  equally  or  there  may  be 
a  long  and  a  short  one,  and  occasionally  three  distinct  curves  may  be 
present.  If  the  primary  curve  is  slight,  the  secondary  curvature  will 
be  slight  also,  and  the  primary  curve  persists  doubtless  for  a  time  be- 
fore the  secondary  distortion  appears.  In  some  instances  the  spine 
may  be  bent  laterally  into  one  long  curve,  "  total  scoliosis.' '  (Fig. 
68.)  This  is  probably,  in  many  instances  at  least,  the  initial  stage  of 
the  ordinary  type  of  scoliosis,  the  long  curve  being  afterwards  divided, 
although  it  may  persist.  In  childhood,  total  scoliosis  is  often  com- 
bined with  general  posterior  curvature  and  it  is  peculiar  in  that  the 
torsion  of  the  vertebrae  may  be  toward  the  concave  instead  of  the  con- 
vex side,  as  is  usual,  the  torsion  representing  probably  the  early  stages 
of  the  secondary  or  compensatory  curve. 


ROTATION  AND  LATERAL  DEVIATION. 


123 


It  Jaas  been  stated  that  deformity  of  one  part  of  the  spine  is  usu- 
ally baldnced  by  deformity  of  another.  This  enables  the  trunk  to 
hold  the  erect  posture  and  it  restores  its  general  symmetry.  If,  how- 
ever, a  long  lateral  or  a  long  posterior  curvature  persists,  the  weight 
<;an  be  balanced  only  by  swaying  the  entire  body  on  the  pelvis,  in  the 


Fig.  71. 


Primary  lumbar  curvature  to  the  left.    A  "  flat'back  ' 
but  slight  lateral  curvature. 


marked  rotation  with- 


direction  opposed  to  the  distortion.     This  restores  the  balance,  but 
not  the  symmetry.     (Fig.  63.) 

Rotation  and  Lateral  Deviation. — Fixed  rotation  of  the  spine 
carries  with  it  of  course  all  the  parts  that  are  attached  to  it.  When 
the  patient  stands  in  the  erect  attitude  the  simple  lateral  distortion  is 
most  noticeable,  but  when  the  body  is  bent  forward  the  twist  of  the 
trunk  becomes  the  prominent  deformity.  (Fig.  69.)  If  the  thoracic 
region  is  involved,  the  ribs,  on  the  side  toward  which  the  spine  is 


124 


LATERAL    CURVATURE   OF  THE  SPINE. 


Fro.  72. 


rotated,  project  backward  and  on  the  other  side  of  the  spine  there  is 
an  abnormal  flatness  or  depression.  The  projection  of  the  ribs  due  to 
the  twisting  of  the  thorax  is  far  more  noticeable  than  is  the  simple 
twisting  of  the  free  portions  of  the  spine  in  the  neck  or  loins ;  and 
in  these  regions  the  projecting  transverse  processes  covered  by  the  thick 
layers  of  muscles  yet  unaccompanied  by  marked  lateral  deviation, 
may  cause  mistakes  in  diagnosis.  In  the  cervical  region,  as  an  accom- 
paniment of  acute  torticollis,  the  projection  may  be  mistaken  for  ab- 
scess; and  in  the  lumbar  re- 
gion it  has  been  mistaken  for  a 
new  growth  attached  to  the 
spine. 

Although  persistent  lateral 
curvature  of  the  spine  is  al- 
ways accompanied  by  rota- 
tion, the  degree  of  rotation 
does  not  always  correspond  to 
that  of  the  more  evident  lat- 
eral deviation.  In  the  instan- 
ces cited,  extreme  rotation  in 
the  lumbar  region  may  exist 
with  but  slight  lateral  distor- 
tion ;  while  in  other  cases  the 
body  appears  to  be  greatly 
displaced  to  one  side,  although 
there  may  be  comparatively 
little  fixed  rotation.  Again, 
as  has  been  stated,  the  lateral 
deviation  of  the  trunk  is  usu- 
ally more  noticeable  than  the 
rotation,  which  in  the  slightest 
grades  of  deformity  is  only 
made  apparent  when  the  pa- 
tient is  bent  forward  so  that 
the  back  may  be  inspected  in 
the  horizontal  position.  It 
may  be  noted  also  that  the  de- 
gree of  habitual  lateral  distor- 
tion of  the  body  does  not  correspond  to  the  degree  of  fixed  distortion. 
One  individual,  by  voluntary  effort,  may  practically  conceal  advanced 
deformity,  while  another  who  makes  no  effort  to  correct  the  improper 
posture,  appears  to  be  greatly  distorted  although  the  fixed  changes 
may  be  very  slight. 

The  effects  of  the  deformity,  both  general  and  local,  depend  upon  its 
situation  and  its  degree.  In  one  instance  it  may  be  so  slight  as  to  pass 
unnoticed,  and  in  another  the  distortion  may  equal  that  of  Pott's  dis- 
ease. (Fig.  80.)  If  compensation  be  perfect,  that  is,  if  the  deformity 
is  equally  distributed  on  either  side  of  the  median  line,  the  general  sym- 


Scoliosis  with  marked  posterior  deformity. 


THE  "HIGH"   SHOULDER  AND   THE  "HIGH"   HIP.  125 

metry  of  the  body  may  be  but  slightly  disturbed.  Or  if  the  compen- 
sation for  the  primary  deformity  of  the  lumbar  region  is  distributed 
throughout  the  remainder  of  the  spine,  noticeable  distortion  may  be 
insignificant,  but  when  there  is  a  long  curve  involving  the  thoracic 
region,  the  lateral  and  posterior  displacement  cannot  be  concealed. 
(Fig.  73.) 

Changes  in  the  Anteeo-Posterior  Contour. — Lateral  distor- 
tion involves  also  secondary  changes  in  the  antero-posterior  outline  of 
the  spine.  When  the  distortion  is  marked  the  stature  is  shortened, 
sometimes  very  noticeably.  This  shortening  is,  of  course,  greater  when 
the  antero-posterior  curves  are  increased  in  addition  to  the  lateral  de- 
viation. And,  in  general,  one  may  recognize  two  types  of  lateral  cur- 
vature, one  in  which  the  back  is  flatter  than  normal,  in  which  the 
antero-posterior  curves  are  diminished,  and  another  in  which  they 
are  increased. 

It  has  been  stated  in  the  account  of  Pott's  disease  that  deformity  in 
one  segment  of  the  spine  always  caused  a  change  in  the  contour  of  the 
spine  as  a  whole,  that  an  obliteration  or  a  lessening  of  the  concavity 
of  the.  lumbar  region  was  accompanied  by  a  corresponding  flattening 
of  the  normal  dorsal  kyphosis.  On  the  other  hand,  an  increase  in  the 
backward  projection  of  the  dorsal  region  caused  an  increase  in  the 
concavity  of  the  parts  below.  It  is  probable  that  the  same  explana- 
tion may  account  for  the  secondary  changes  in  the  antero-posterior 
contour  of  the  spine  in  lateral  curvature.  In  the  one  instance  the 
primary  deformity  is  of  the  lower  region,  and  with  its  accompanying 
backward  twist  of  the  vertebral  bodies  it  lessens  the  lumbar  lordosis 
and  tends  to  flatten  the  back.  (Fig.  71.)  If,  on  the  other  hand,  the 
deformity  begins  in  the  thoracic  region,  the  primary  effect  is  to  increase 
the  backward  projection,  and  this  in  turn  tends  to  exaggerate  the  lum- 
bar lordosis.  (Fig.  72.)  Thus  the  shortening  of  the  trunk  caused  by 
the  lateral  deviation  may  be  to  a  certain  extent  compensated  in  the 
first  instance,  while  in  the  other  both  the  primary  and  secondary  dis- 
tortions tend  to  reduce  the  height. 

The  "  High  "  Shoulder  and  the  "  High  "  Hip. — When  the 
convexity  of  the  primary  curve  is,  for  example,  to  the  left  in  the  lum- 
bar region,  the  trunk  is  displaced  somewhat  to  the  left,  consequently 
the  right  "  hip  "  becomes  abnormally  prominent ;  and  in  compensation 
for  the  displacement  below,  there  is  a  corresponding  twist  in  the  op- 
posite direction  above.  The  spine  bending,  and  at  the  same  time  ro- 
tating toward  the  right,  carrying  with  it  the  ribs,  elevates  the  shoulder 
and  makes  the  scapula  prominent.  Thus  it  is  that  in  the  ordinary  S- 
shaped  curve  the  high  shoulder  and  the  projecting  hip  appear  usually 
upon  the  same  side  of  the  body.  But  in  less  regular  varieties  of  dis- 
tortion, when,  for  example,  there  is  marked  general  lateral  deviation, 
the  high  shoulder  may  be  on  the  opposite  side.  (Fig.  79.)  The  final 
effect,  as  far  as  the  lateral  deviation  is  concerned,  is  much  the  same 
whether  the  curvature  is  primarily  of  the  dorsal  or  of  the  lumbar  re- 
gion, and  there  is  much  uncertainty  as  to  the  relative  frequency  of  the 


126 


LATERAL   CURVATURE  OF  THE  SPINE. 


primary  distortion  because  few  cases  are  seen  in  the  early  stage  or  be- 
fore compensatory  changes  have  appeared. 

Pathology. — Lateral  curvature  of  the  spine  is  a  deformity,  not'a  dis- 
ease, nor  is  it  in  the  ordinary  cases  a  result  of  disease.  For  this  reasou 
the  description  of  the  pathology  which  is  merely  a  more  detailed  ac- 
count of  the  deformity  and  of  its  secondary  effects  upon  the  trunk  and 
its  contents  may,  for  convenience,  precede  the  discussion  of  the  etiology. 

In  such  a  description  one  must  consider  the  spine  as  a  whole,  a 
column  bent  and  twisted,  in  which  each  component  segment  bears  its- 

Fig.  73. 


Scoliosis  with  extreme  lateral  deviation. 


share  of  the  general  distortion.  The  vertebra  at  the  apex  of  each  curve 
shows  the  greatest  change.  If  the  rotation  and  lateral  deviation  is  to 
the  right  the  vertebral  body  is  somewhat  wedge-shaped,  the  apex  of 
the  wedge  being  directed  backward  and  to  the  left.  Its  lateral  diam- 
eter is  increased  and  the  superior  and  inferior  margins  at  the  narrow 
side  overhang  the  center  of  the  body,  increasing  the  lateral  concavity. 
(Fig.  77.)  Similar  accommodative  changes,  although  less  marked,  are 
to  be  found  in  the  articular  processes  and  in  the  laminae  ;  in  fact  all  the 
parts  on  the  concave  side  are  broadened,  shortened  and  lessened  in 


PATHOLOGY. 


127 


vertical  diameter  as  compared  with  those  on  the  convex  side  of  the 
spine.  These  changes  affect  the  shape  of  the  neural  canal,  which  be- 
comes somewhat  ovoid  in  outline,  the  base  being  directed  toward  the 


,  ,\V^A^\;- 


convexity  of  the  curve.  (Fig.  78.)  In  the  vertebrae  included  in  the 
compensatory  curvature,  the  deformities  are  reversed,  and  the  inter- 
mediate segments  show  the  transitional  changes  between  the  two  ex- 


128 


LATERAL  CURVATURE  OF  THE  SPINE. 


tremes.  The  intervertebral  discs  become  wedge-shaped  also,  and  atro- 
phied on  the  side  subjected  to  greatest  pressure,  the  changes  in  these 
softer  tissues  preceding,  undoubtedly,  those  in  the  bones.  The  articu- 
lations of  the  vertebrae  become  changed  in  shape  and  position  in  the 
general  adaptation  to  the  deformity  and  the  ligaments  are  shortened  or 
lengthened  according  to  their  relation  to  the  distortion. 

On  section,  tlie  internal  structure  of  the  vertebrse  shows  the  same 
adaptive  changes  that  are  evident  on  the  exterior.  In  the  narrowed 
parts  of  the  bones  that  bear  the  weight,  the  tissue  is  thick  and  com- 
pact, and  on  the  opposite  side  it  is  atrophied  from  disuse. 


Fig.  7 


Scoliotic  vertebrae.     (Hoffa.) 


The  mobility  of  the  spine  is  lessened  by  these  changes  in  its  shape 
and  structure ;  primarily  by  the  distortion,  and  by  the  shortening  of 
the  tissues  on  the  concave  side,  finally  by  the  interference  of  the  newly 
formed,  or  transformed  bone  which  is  thrown  out  about  the  margins  of 
the  vertebrae  and  the  articular  processes,  and  by  the  distortions  of  the 
vertebral  bodies.  Thus  in  fixed  deformity  there  may  be,  at  the  points 
of  greatest  distortion,  practical  anchylosis.  The  muscles  of  the  back, 
both  intrinsic  and  extrinsic,  undergo  adaptative  changes,  and,  as  a  rule, 
they  are,  in  general,  relatively  weak,  and  especially  so  if  the  motions 
of  the  spine  are  much  interfered  with. 

The  distortion  of  the  vertebral  column  causes,  of  course,  a  distortion 


PATHOLOGY. 


129 


of  the  trunk  of  which  it  is  the  support,  and  this  distortion  is  of  the 
greatest  importance  in  its  effect  upon  the  thorax.  The  deformity  of 
the  thorax  is  somewhat  difficult  to  describe  because  the  distortion  of 
the  dorsal  vertebrse  does  not  affect  the  thorax  equally,  thus  it  is  not 
twisted  as  a  whole,  nor  flexed  as  a  whole.  The  nature  of  the  distor- 
tion may  be  better  understood  by  considering  the  sternum  as  a  fixed 
point;  this,  as  a  matter  of  fact,  it  is,  as  compared  with  the  spine.  At 
the  apex  of  the  convexity  of  the  curve  the  ribs  are  drawn  sharply 
backward  with  the  transverse  processes  to  which  they  are  attached ;  their 
angles  project  by  the  side  of,  and  beyond,  sometimes  covering  and  con- 
cealing the  spinous  processes,  and  the  lateral  convexity  of  the  chest  is 
diminished  or  lost.  On  the  opposite  side  the  back  is  broadened  and  flat- 
tened. The  effect  of  the  rota- 
tion is  to  diminish  the  capacity  Fig.  78. 
of  the  chest,  on  the  convex  side 
and  to  increase  that  of  the  con- 
cave side.  (Fig.  79.)  On  the 
convex  side  the  ribs  are  ele- 
vated, and  their  inclination  is 
increased.  On  the  concave  side 
the  intercostal  spaces  are  nar- 
rowed and  the  inclination  is 
lessened.  (Fig.  75.)  The  an- 
tero-posterior  diameter  of  the 
chest  is  increased  or  dimin- 
ished according  to  the  change 
in  the  antero-posterior  contour 
of  the  spine.  If  the  dorsal 
kyphosis  is  exaggerated,  the 
effect  is  to  deepen  the  chest 
(Fig.  72) ;  if  it  is  diminished, 
the  diameter  of  the  thorax  is 
correspondingly  lessened. 

The  cervical  section  of  the 
spine  is  not  often  involved,  to 
a  marked  degree,  at  least  in  the  lateral  deformity.  But  in  extreme  cases, 
in  which  the  neck  and  head  are  habitually  distorted,  the  skull  may  show 
secondary  changes  similar  to  those  induced  by  persistent  torticollis. 

At  the  other  extremity  of  the  spine,  the  pelvis  is  not,  as  a  rule, 
noticeably  deformed.  In  some  instances  the  oblique  diameter,  opposed 
to  the  convexity  of  the  lumbar  deformity,  may  be  increased,  and  if  the 
lateral  deviation  of  the  lumbar  spine  is  extreme,  the  pelvis  may  be  so 
tilted  that  the  limb  on  the  elevated  side  becomes  practically  shorter 
than  its  fellow. 

In  the  changes  that  have  been  described,  the  contents  of  the  trunk 

participate  to  a  greater  or  less  degree.     The  lung  on  the  convex  side 

is  more  or  less  compressed  by  the  distorted  ribs  and  by  the  displaced 

vertebral  bodies.     The  heart  may  be  displaced  laterally  or  upward, 

0 


Change  in  shape  of  the  spinal  canal,  broader  on  the 
convex  side.     (Hoffa.) 


130  LATERAL  CURVATURE  OF  THE  SPINE. 

according  to  the  position  of  the  deformity,  and  the  blood  vessels  are 
changed  in  direction,  and,  it  may  be,  altered  in  calibre.  In  those  cases 
in  which  the  thorax  is  markedly  distorted,  the  effect  is  similar  to  that 
of  the  deformity  of  Pott's  disease;  respiration  is  shallow  and  rapid, 
the  pulse  rate  is  usually  increased  and  other  evidences  of  interference 
with  the  vital  functions  may  be  apparent.  The  abdominal  organs  are 
affected  doubtless,  in  a  similar  manner,  but  symptoms  due  to  this  cause 
are  not,  as  a  rule,  as  clearly  marked.^ 

Etiology — Relative  Frequency. — Lateral  curvature  of  the  spine  is 
one  of  the  most  common  of  deformities.  In  the  past  fifteen  years, 
1885-1899,  3,252  cases  were  recorded  in  the  Out-patient  Department 

Fig.  79. 


Deformity  of  the  thorax  in  scoliosis.     (Hoffa.) 

of  the  Hospital  for  Ruptured  and  Crippled,  a  number  only  exceeded 
by  that  of  bow  legs,  of  which  5,030  cases  were  treated  during  the  same 
period. 

The  only  statistics  bearing  upon  the  relative  frequency  of  lateral 
curvature  among  children  in  general  are  those  of  Drachmann  who 
found  among  28,125  school  children  (16,789  boys,  11,386  girls)  of 
Denmark  368  cases  of  scoliosis  (1.3  per  cent.). 

Sex. — Lateral  curvature  of  the  spine  is  far  more  common  among 
females  than  males.  Of  the  3,252  cases  referred  to  2,554  (78.5  per 
cent.)  were  in  females  and  698  (21.4  per  cent.)  were  in  males. 

The  lowest  percentage  of  males  in  any  one  of  the  fifteen  years  was 
14.8,  the  highest  25.1.  This  proportion  of  one  male  to  four  females 
is  somewhat  larger  than  in  the  smaller  groups  of  cases  reported  by 
other  observers. 

The  unequal  distribution  of  the  deformity  between  the  sexes  is  of 
great  interest  as  bearing  on  the  question  of  etiology ;  especially  so  a 

^  Bachnian,  Die  Veranderungen  an  den  inneren  Organen  bei  liocligradigen  Skoli 
sen  und  Kyphoskoliosen.     Eibliotlieca  Medica  Ab.  D.  1,  H.  4,  1900. 


ETIOLOGY—STATISTICS.  131 

in  the  cases  that  develop  in  early  childhood,  sex  appears  to  exercise 
practically  no  influence.  It  has  been  suggested  that  curvature  of  the 
spine  in  a  girl  is  looked  upon  with  more  solicitude  by  the  mother  than 
is  the  same  deformity  in  a  boy,  therefore  more  girls  are  brought  for 
treatment.  There  may  be  some  basis  for  this  argument,  for  it  is  cer- 
tain that  distortion  of  the  lower  extremities  are  considered  of  greater 
importance  in  male  than  in  female  children  because  of  the  concealment 
to  be  aflfbrded  by  the  skirts,  if  the  deformity  is  not  outgrown.  But 
granting  that  statistics  are  somewhat  unreliable,  there  can  be  no  doubt 
but  that  this  deformity  is  far  more  common  among  girls  than  boys  and 
that  the  disproportion  may  be  explained,  in  great  part  at  least,  by  the 
differences  in  dress  and  in  manner  of  life. 

Age. — 1,299  (39.9  per  cent.)  of  the  3,252  patients  referred  to  were 
less  than  fourteen  years  of  age.  1,576  (48.4  per  cent.)  were  between 
fourteen  and  twenty-one.  377  (11.6  per  cent.)  were  more  than  twenty- 
one  years  of  age.  These  statistics  simply  show  the  age  of  the  patients 
at  the  time  treatment  was  sought,  and  they  are  of  little  value  as  an 
indication  of  the  age  at  which  deformity  might  have  been  detected 
had  it  been  looked  for. 

There  is  no  reason  to  suppose  that  lateral  curvature  of  the  spine 
differs  in  its  etiology  from  similar  deformities  of  other  parts,  except 
in  so  far  as  each  region  of  the  body  is  more  or  less  susceptible  to  de- 
forming influences  at  one  time  than  another. 

For  example,  rhachitic  deformities  of  the  upper  extremities  are 
practically  never  seen  except  in  infancy,  and  they  begin  to  correct 
themselves  when  the  erect  posture  is  assumed  or  at  the  very  time  when 
distortions  of  similar  origin  of  the  lower  extremities  develop.  But 
when  deformities  of  this  class  appear  in  later  childhood  or  adolescence 
it  may  be  assumed  that,  in  many  instances  at  least,  the  tendency 
toward  the  particular  deformity,  or  even  a  slight  degree  of  deformity, 
was  acquired  at  an  early  age,  that  it  remained  latent  until  the  condi- 
tions appeared  which  favored  its  further  development.  This  point  is 
illustrated  by  the  statistics  of  Eulenburg  of  1,000  cases  of  lateral 
curvature  analyzed  with  reference  to  the  inception  of  the  deformity. 

Between  birth  and  the  sixth  year 78 

Between  the  sixth  and  seventh  years 216 

Between  the  seventh  and  tenth  years 564 

Between  the  tenth  and  fourteenth  years 107 

After  the  fourteenth  year 35 

1,000 

It  will  be  noted  that  but  142  (14.2  per  cent.)  of  the  patients  were 
more  than  fourteen  years  of  age  as  contrasted  with  the  general  statistics 
of  the  Hospital  for  Ruptured  and  Crippled,  in  which  60  per  cent,  were 
beyond  this  age. 

Dr.  Walter  Truslow,  who  for  several  years  has  had  the  immediate 
charge  of  the  treatment  of  lateral  curvature  at  the  Hospital  for  Ruptured 
and  Crippled,  has  prepared  for  me  statistics  of  a  number  of  the  cases 


132 


LATERAL   CURVATURE  OF  THE  SPINE. 


under  treatment  by  gymnastic  exercises,  which    illustrate  the  same 
point. 

A. 


Age  When  Treatment  was  Begun. 


Age  when  examined.  Males. 

4  years 0 


5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

23 

24 

32 


Females. 
1 
1 
1 

2 

7 

4 

7 
13 
16 
28 
25 
21 
14 

6 

2 

1 

1 

4 

1 

1 

1 


44 


157 


B. 

Age  when  the  Deformity  was 


Congenital  2 

During  infancy 19 

Between   3    and   6   years 16 

'       41 

'       62 

'       27 

'       14 

20 


Discovered. 

Males. 


6 

"    10 

"         10 

"    13 

"         13 

"    15 

Over        15 

Unknown.   . 

201 


sex  not  stated. 

10 
10 

6 

3 

3 

"32" 


Total. 

1 

1 

2 

6 
11 

8 

9 
16 
19 
32 
30 
24 
22 

8 

3 

1 

1 

4 

1 

1 

1 


201 


P'emales. 


6 
31 
56 
24 
11 

128" 


But  44  of  the  181  patients  (22.6  per  cent.)  were  more  than  13 
years  of  age  at  the  time  when  the  deformity  was  first  noticed,  al- 
though nearly  50  per  cent,  were  older  when  treatment  was  applied  for. 
In  the  first  table  it  will  be  noted  that  of  the  38  patients  who  were  10 
years  of  age  or  less,  15  or  about  40  per  cent,  of  the  number  were 
males.  In  25  of  the  37  patients  in  whom  the  deformity  is  supposed 
to  have  developed  at  or  before  the  sixth  year,  rhachitis  was  the  ap- 
parent cause. 

Lateral  curvature  of  the  spine  is  one  of  the  penalties  of  the  erect 
posture,  and  the  force  of  gravity  must  be  considered  both  as  a  predis- 
posing and  as  an  exciting  cause  of  the  deformity. 


ETIOLOGY.  133 

The  more  direct  tendency  of  the  force  of  gravity  is  to  cause  the  body 
to  fall  forward  and  to  increase  the  posterior  curvature  of  the  spine,  but 
whenever  there  is  a  persistent  inclination  of  the  spine  to  one  or  the 
other  side,  this  inclination  is  likely  to  be  increased  to  deformity  under 
favoring  conditions.  These  favoring  conditions  would  include  general 
weakness  from  any  cause ;  overwork  that  may  induce  fatigue,  and  all 
factors,  mechanical  or  otherwise,  that  may  add  to  the  difficulty  of 
holding  the  trunk  erect  under  the  pressure  of  the  superincumbent 
weight. 

Although  it  is  not  difficult  to  suggest  the  predisposing  causes  of 
lateral  curvature,  it  is  by  no  means  as  easy  to  point  out  the  direct 
cause  of  the  original  inclination  of  the  spine  to  one  or  the  other  side  of 
the  median  line  that  is  the  first  step  toward  fixed  deformity.  In  a 
certain  number  of  cases,  however,  the  relation  between  cause  and  effect 
is  sufficiently  evident  and  these  causes  may  be  enumerated  before  con- 
sidering the  larger  class  in  which  the  etiology  is  more  obscure. 

1.  Lateral  curvature,  secondary  to  deformity  of  other  parts. 

2.  Static  or  mechanical  deformity. 

3.  Deformity  secondary  to  disease  of  the  nervous  system. 

4.  Deformity  secondary  to  disease  of  the  thoracic  organs. 

5.  Incidental  deformity. 

6.  Deformity  due  to  occupation. 

7.  Congenital  deformity. 

8.  Rhachitic  deformity, 

1.  Lateral  Cuevature  Secondary  to  Deformity  Else- 
where.— (a)  Lateral  curvature  of  the  spine  may  be  a  compensatory 
effect  of  torticollis,  either  congenital  or  acquired.  (6)  It  may  be 
induced  by  distortion  or  inequality  of  the  lower  extremities.  For 
example,  fixed  adduction  of  the  thigh  necessitates  an  upward  tilting  of 
the  pelvis  whenever  the  limb  is  brought  into  the  normal  line,  whether 
the  patient  is  standing,  sitting  or  lying ;  and  this  deformity  when 
extreme,  may  induce  lateral  curvature  even  in  bed-ridden  patients. 
The  same  effect  is  sometimes  observed  in  certain  instances  of  inequality 
of  the  length  of  the  lower  extremities.  In  the  erect  posture  the  pelvis 
is  tilted  downward  on  one  side,  and  this  in  turn  necessitates  a  twist 
of  the  spine. 

2.  Static  Deformity. — Simple  inequality  of  the  limbs  does  not 
appear  to  be  a  common  cause  of  fixed  deformity  because  its  influence 
ceases  in  the  sitting  and  reclining  postures,  and  because  the  inequality 
is  so  often  compensated,  if  it  be  extreme,  by  walking  on  the  toe  or  by 
raising  the  sole  of  the  shoe. 

An  increase  in  the  length  of  a  limb,  such  as  may  be  caused  by  a 
fixed  equinus  of  the  foot,  seems  to  have  more  influence  in  causing 
secondary  deformity  than  does  shortening,  possibly  because  no  attempt 
is  made  to  compensate  for  the  inequality. 

3.  Lateral  Curvature  Secondary  to  Paralysis. — Lateral 
deformity  of  the  spine  may  be  caused  indirectly  by  a  number  of  dis- 
tinct diseases  of  the  nervous  system,  but  in  this  connection  only  one 


134 


LATERAL   CURVATURE  OF  THE  SPINE. 


need  be  considered — anterior  poliomyelitis.  This  form  of  paralysis 
may  act  in  several  ways.  It  may  induce  deformity  by  distortion  of  a 
lower  extremity  or  by  inequality  in  the  length  of  the  limbs  due  to  re- 
tardation of  growth.  It  may  predispose  to  deformity  by  the  general 
weakness  that  it  causes,  or  the  trunk  may  be  unbalanced  by  loss  of 
function  in  one  of  the  upper  extremities,  but  the  more  extreme  cases 
of  deformity  are  caused  by  unilateral  paralysis  of  the  muscles  of  the 
trunk.  As  a  result,  the  expansion  of  one  side  of  the  thorax  is  inter- 
fered with  and  the  unaffected, 

or  less  affected,  side  taking  on  Fig.  81. 

increased  activity,  develops  at 
the  expense  of  the  disabled  part. 


Scoliosis  following  empyema  at  the  age 
of  2  years.    Present  age  19  years. 


Scoliosis  secondary  to  lumbar  Pott's  disease  in  early 
childhood. 


Thus  the  convexity  of  the  curve  is  usually  toward  the  sound  side. 
4.  Lateral  Curvature  Secondary  to  Disease  within  the 
Thoracic  Walls. — The  most  common  cause  of  deformity  of  this  class 
is  persistent  empyema.  The  lung  is  primarily  compressed  by  the 
effused  fluid,  and  its  function  is  finally  impaired  or  abolished  by  the 
adhesions  that  form  between  it  and  the  chest  wall,  as  well  as  by  the 
extension  of  the  disease  to  its  structure.  As  a  result,  the  side  of  the 
chest  is  retracted  while  the  function  of  the  unaffected  lung  is  increased. 


ETIOLOGY.  135 

(Fig.  80.)     Thus,  as  in  paralysis,  the  spine  curves  with  the  convexity 
toward  the  active  side. 

Other  affections  of  the  kings  that  interfere  with  the  function  of  one 
side  may  induce  lateral  curvature,  but  the  influence  is  less  marked  and 
direct  than  in  empyema. 

5.  Incidental  Lateeal  Curvature. — Lateral  curvature  may  be 
caused  by  direct  injury  or  by  disease  of  the  spine,  for  example  by  frac- 
ture or  by  Pott's  disease.  (Fig.  81.)  Distortion  as  a  symptom  of 
sacro-iliac  disease,  or  the  more  marked  deformity  caused  by  sciatic  or 
lumbar  neuritis  (Fig.  67),  may  if  persistent  finally  induce  slight  per- 
manent deformity,  but  such  cases  hardly  deserve  special  considera- 
tion. 

6.  Lateral  Curvature  due  to  Occupation. — Lateral  curvature 
of  milder  degree  is  incidental  to  certain  occupations  that  require  habit- 
ual inclination  of  the  body.  It  is  said  to  be  very  common  among 
stone  cutters,  for  example.  Such  deformity  developing  after  the 
growth  of  the  body  has  been  attained,  is,  of  course,  of  interest  as 
throwing  light  upon  the  etiology  of  the  ordinary  form  of  lateral  curva- 
ture. For  if  habitual  occupation  can  thus  change  the  contour  of  the 
developed  spine,  it  is  evident  that  similar  postures,  though  far  less  con- 
stant, may  influence  the  spine  of  a  growing  child,  particularly  in  one 
predisposed  to  such  distortion. 

7.  Congenital  Lateral  Curvature. — Congenital  scoliosis  is 
uncommon  (Fig.  82)  in  infants  otherwise  normal,  and  but  few  cases 
have  come  under  my  observation  at  an  age  sufficiently  early  to  make 
the  diagnosis  absolutely  certain.  One  case,  in  an  otherwise  well-formed 
male  infant,  was  seen  at  the  age  of  three  months.  There  were  well- 
marked  lateral  deviation  and  rotation  in  the  dorsal  region  that  had 
attracted  attention  soon  after  birth.  A  second  case,  in  a  female  child, 
was  seen  at  about  the  same  age.  The  deformity  was  extreme,  and 
contracted  tissues  on  the  concave  side  prevented  the  straightening  of 
the  spine.     There  was  also  an  accompanying  lumbar  hernia. 

The  first  patient  was  cured  by  manipulation  and  posture  before  the 
completion  of  the  first  year ;  the  second,  now  six  years  of  age,  is  still 
under  treatment.  A  number  of  cases  have  been  collected  from  liter- 
ature by  Hirschberger.^ 

8.  Rhachitic  Lateral  Curvature. — Rhachitis  predisposes  to 
deformity  of  all  parts  of  the  body  by  weakening  the  resistance  of  all 
the  tissues.  As  is  well  known,  the  common  deformities  from  this  cause 
are  the  so-called  rhachitic  kyphosis  that  develops  in  the  sitting  child, 
and  the  distortions  of  the  lower  extremities  in  those  who  stand  and 
walk.  Lateral  curvature  of  the  spine  sometimes  accompanies  the 
kyphosis  in  those  who  do  not  walk,  or  it  may  exist  independently  of 
it.  The  lateral  inclination  is  induced  doubtless  by  the  manner  of  sit- 
ting or  by  the  manner  in  which  the  child  is  supported  on  the  mother's 
arm  ;  for  at  this  period  of  rapid  growth  and  increased  susceptibility 
to  deforming  influences,  even  slight  and  temporary  causes  of  this  na- 

^  Beitrag  zur  Lehr  der  Angeboren  Skoliosen,  Zeits.  f.'Ortho.  Chir.,  B.  7,  H.  1,  1899. 


136 


LATERAL   CURVATURE  OF  THE  SPINE. 


ture  may  be  sufficient  to  induce  the  distortion.  (Fig.  83.)  Again,  when 
the  child  begins  to  walk,  the  tilting  of  the  pelvis  due  to  distortion  of  the 
limbs,  for  example  to  unilateral  knock  knee,  may  also  serve  to  disturb 
the  equilibrium  of  the  body  and  thus  to  induce  lateral  distortion. 

How  common  rhachitic  lateral  curvature  may  be  it  is  impossible 
to  say,  but  it  is  probable  that  if  all  rhachitic  infants  and  children 
were  carefully  examined,  this  deformity  would  be  discovered  in 
many  instances  in  which  its  existence  had  not  been  suspected. 

In  about  1 5  per  cent,  of  the  cases 
tabulated  by  Truslow  the  influence  Fig.  83. 


Fig.  82. 


Congenital  scoliosis.  Rhachitic  scoliosis. 

of  one  or  more  of  the  causes  that  have  been  enumerated  seemed  to  be 
apparent,  viz.: 

Congenital  deformity 2 

Torticollis 2 

Empyema 4 

Anterior  poliomyelitis 3 

Inequality  of  the  legs  of  more  than  ^  inch 6 

Rhachitis 1^ 

Total 30 


ETIOLOGY— POSTURES.  137 

In  the  remaining  cases,  85  per  cent.,  the  direct  cause  of  the  de- 
formity ,was  somewhat  conjectural. 

Hereditary  Influence. — By  many  writers  the  influence  of  heredity  is 
considered  an  important  factor  in  the  etiology.  That  there  is  such  an 
influence,  predisposing  to  disease  as  well  as  to  deformity,  is  undoubted, 
but  it- is  very  difficult  to  establish  its  connection  with  the  ordinary  cases. 
In  11  of  201  cases,  lateral  curvature  was  present  in  either  the  father 
or  mother  of  the  patient.  And  in  17  others  a  brother  or  sister  of 
the  patient  was  deformed  in  a  similar  manner. 

Occupation. — It  is  well  known  that  occupation  may  induce  de- 
formity in  the  adult  and  one  looks  naturally  to  occupation  as  a  factor 
in  the  causation  of  lateral  curvature  in  childhood.  Occupation  in 
this  class  implies  school,  and  it  may  be  assumed  that  the  sitting  pos- 
ture during  school  hours  may  cause  fatigue  especially  if  the  chair  is 
unsuitable  or  uncomfortable.  (Figs.  84,  85.)  Under  the  influence 
of  fatigue  an  improper  attitude  is  likely  to  be  assumed  which  may 
become  habitual,  its  character  being  influenced  by  the  arrangement  of 
the  light  or  by  the  shape  of  the  desk.  When  a  habit  of  posture  is 
acquired  it  is  likely  to  persist  when  the  sitting  posture  is  assumed  else- 
where than  at  school  and  the  greater  liability  of  girls  to  the  deformity, 
may  be  explained  in  part  by  the  fact  that  they  sew,  or  read,  or  play  on 
the  piano,  while  boys  are  usually  engaged  during  the  same  period  in 
active  exercise. 

In  Truslow's  tables  the  occupation  is  noted  in  400  cases  of  lateral 
curvature  ;  also  other  habits  that  may  have  influenced  the  deformity. 

Occupation. 

School  285 

Factory 19 

Clerk  13 

Domestic    8 

Millinery,  Dressmaking,  etc 8 

Messenger 3 

Housewife 3 

Teacher 2 

No  occupation 59 

Total .400 


Posture. 

Weight  on  right  foot 48 

"        "   left        "    48. 

Carries  books  or  baby  on  right  arm 38 

"            "       "       "     "   left      "    36 

Sits  at  desk  or  work  in  faulty  attitude 57 

Carries  heavy  load  on  one  shoulder 2 

Excessive  use  of  right  arm  in  occupation 3 

Total 232 


96 
74 


The  sitting  posture  is  not  the  only  one  in  which  improper  attitudes 
may  be  persistently  assumed,  in  fact  it  has  been  suggested  that  the 
posture  during  sleep  may  influence  the  inclination  of  the  body  during 


138 


LATERAL   CURVATURE  OF  THE  SPINE. 

Fig.  84. 


Posture  induced  by  improper  desk  and  chair.     (Scudder.) 
Fig.  85. 


Posture  induced  by  improper  chair.     (Scudder.) 


VARIETIES  OF  DEFORMITY.  139 

the  hours  of  activity.  But  the  sitting  posture  is  the  one  in  which  the 
muscular  support  is  most  likely  to  be  relaxed,  and  in  which  a  tendency 
toward  lateral  inclination  is  most  likely  to  be  acquired,  since  children 
do  not  often  retain  a  fixed  attitude  in  the  erect  posture  for  any  length 
of  time.  For  this  reason,  inequality  in  the  length  of  the  limbs  is  of 
less  importance  as  a  cause  of  distortion  than  it  would  otherwise  be. 
Bradford  and  Lovett  record  an  observation  of  the  attitudes  of  67 
healthy  adults  undergoing  a  written  examination.  At  the  end  of  the 
second  hour  a  lateral  inclination  of  the  body  was  evident  in  all,  and 
in  three-fourths  of  the  number  the  general  inclination  of  the  body 
was  to  the  right.  In  at  least  this  proportion  of  the  cases  of  lateral 
curvature  the  type  of  fixed  deformity  is  to  the  left  in  the  lumbar  and 
to  the  right  in  the  dorsal  region,  and  it  is  natural  to  look  upon  the 
occupation  as  the  important  factor  in  determining  the  direction  of  the 
deformity.  If  it  be  assumed  that  the  distortion  is  caused  or  influenced 
by  the  attitude  assumed  dnring  school  hours  it  would  appear  that  the 
primary  deformity  should  be  more  often  of  the  lumbar  region,  for  in 
the  sitting  posture  the  lumbar  lordosis  is  lessened  or  lost,  thus  the 
bodies  of  the  vertebrae  in  the  lumbar  region  would  be  subjected  to 
greater  pressure  than  in  the  dorsal  region,  a  pressure  which  might  in- 
duce the  changes  in  the  bones  that  accompany  deformity. 

The  possibility  of  distinguishing  the  varieties  of  lateral  curvature 
in  which  the  primary  distortion  is  lumbar  from  those  in  which  it  is 
dorsal,  by  the  flattening  of  the  dorsal  kyphosis  in  the  former,  and  its 
exaggeration  in  the  latter  instance,  has  been  mentioned. 

Varieties  of  Deformity. — According  to  the  statistics  from  various 
sources  about  three-fourths  of  the  well-developed  double  curves  of  the 
spine  are  convex  to  the  right  in  the  dorsal  and  to  the  left  in  the  lumbar 
region,  and  as  the  distortion  of  the  thorax  is  the  more  noticeable  of 
the  two  it  usually  classifies  the  deformity  as  right  or  left.  The  dorsal 
curvature  may  be  either  primary  or  secondary,  and  the  relative  frequency 
of  the  original  deformity,  whether  lumbar  or  dorsal,  is  in  doubt  with 
the  probabilities  in  favor  of  the  former. 

Summary  of  Varieties  of  Deformity  of  the  Spine  under  treatment 
1899-1900,  at  the  Hospital  for  Ruptured  and  Crippled,  tabulated  by 
Dr.  Truslow. 

1.  Simple  Antero-posterior  Deformities. 

{a)  Kyphosis 10 

Kypho-lordosis 1 

Lordosis 1 

12 

Bound  Shoulders. 

(b)  Abducted  scapulae 7 

Elevated  scapulae 2 

^  Total,     21 


140  LATERAL   CURVATURE  OF  THE  SPINE. 

2.  Antero-posteriob  Abnormalities  most  Marked,  but  Accompanied 
BY  Lateral  Deviation. 

(a)  With  single  lateral  curve 14 

(b)  With  double  lateral  curve 16 

(c)  With  triple  lateral  curve 7 

37 

3.  Rotation  most  Marked,  but  Accompanied  by  Lateral 
Deviation. 

(a)  With  double  lateral  curves 22 

(b)  With  triple  lateral  curves 8 

30 

4.   Lateral  Deviation  most  Marked,  Direction  of  the  Curves. 
Right  Dorsal,   Left  Lumbar  Type. 

(a)  Single  lateral  curve 22 

(b)  Double  lateral  curve 71 

(c)  Triple  lateral  curve 6 

99 

Left  Dorsal,   Right  Lumbar  Type. 

(a)  Single  lateral  curve 3 

(&)  Double  lateral  curve 8 

(c)  Triple  lateral  curve 3 

14  Total,  201 

It  will  be  noted  that  in  21  instances  antero-posterior  deformity  ex- 
isted without  lateral  deviation,  and  that  in  37  instances  it  was  accom- 
panied by  lateral  deviation.  In  the  remaining  144  cases,  rotation  was 
more  marked  than  lateral  deviation  in  30  cases,  and  lateral  deviation 
more  marked  than  rotation  in  113.  In  the  entire  number  of  cases  in 
which  lateral  deviation  was  present  it  was  single  in  39  cases,  double 
in  117  cases,  triple  in  24  cases. 

In  373  cases  of  lateral  curvature  tabulated  by  Liining  and  Schul- 
thess  the  deformity  was  as  follows  :^ 

Left.  Right.  Total. 

Total  scoliosis  (single  curve  affect- 
ing the  entire  spine) 79  16  95 

Lumbar  scoliosis  (single  curve  lim- 
ited to  the  lumbar  region) 14  3  17 

Lumbo- dorsal  scoliosis  (single  curve 

limited  to  lumbo-dorsal  region)...     49  60  109 

Complicated  scoliosis. 

(a)  Right  dorsal,  left  lumbar 123 

(6)  Left  dorsal,  right  lumbar _29  152 

171  202  373 

It  will  be  noted  that  a  very  large  proportion  of  these  cases  were  in 
the  early  stage  of  deformity  as  indicated  by  the  absence  of  compen- 
satory curves;  that  in  82  per  cent,  of  the  112  cases  in  which  the 
curve  was  general  or  most  marked  in  the  lumbar  region,  the  inclina- 
tion was  to  the  left,  and  of  the  complicated  or  more  fully  developed 
'  Zeits.  fur  Orth.  Chir.,  Bd.  V. 


DIAGNOSIS.  141 

cases  in  which  the  curve  was  double,  80  per  cent,  were  of  the  right 
dorsal  left  lumbar  type. 

Symptoms. — In  the  large  proportion  of  cases  the  first  symptom  of 
the  aifection  is  the  deformity.  This  is  often  discovered  by  the  dress- 
maker at  the  age  when  the  clothing  is  made  to  fit  the  figure  more  closely. 
In  certain  instances  the  deformity  may  be  preceded  or  accompanied  by 
pain.  This  was  present  to  a  greater  or  less  degree  in  about  one-quarter 
of  the  cases  examined  by  Truslow.  Pain  may  be  simply  the  discom- 
fort or  the  dragging  sensation  of  fatigue,  usually  referred  to  the  lumbar 
region,  or  it  may  be  severe  and  neuralgic  in  type.  The  latter  variety 
is  more  common  in  the  cases  in  which  the  deformity  is  extreme.  It  is 
said  to  be  the  result  of  pressure  on  nerves,  but  this  is  doubtful  as  it 
is  often  referred  to  the  convex  as  well  as  to  the  concave  side.  There 
are  also  more  general  symptoms  of  a  neurasthenic  or  hysterical  nature 
that  may  be  due  in  part  to  the  deformity  and  in  part  to  the  debility 
of  which  it  may  be  a  result  or  accompaniment.  For  it  must  be  borne 
in  mind  that  lateral  curvature  is,  in  many  instances,  symptomatic  of 
debility,  as  is  shown  by  the  fact  that  it  is  often  accompanied  by  other 
deformities,  particularly  by  the  weak  foot.  In  many  instances  symp- 
toms of  weakness  and  awkwardness  precede  the  deformity.  Truslow 
states  that  in  a  large  proportion  of  the  cases  investigated  the  patients 
had  been  distinctly  less  active  than  their  companions,  that  they  did 
not  enjoy  exercise  and  were  inclined  to  lead  sedentary  lives.  Tesch- 
ner  ^  has  called  attention  to  the  same  peculiarity.  He  states  that  the 
patients  are  often  indiiferent,  apathetic  and  lazy.  He  has  noted  also 
a  peculiar  lack  of  coordination  and  muscular  control  as  a  common 
symptom.  These  symptoms  apply  particularly  to  the  period  of  adoles- 
cence, the  time  of  rapid  growth  and  instability,  when  any  latent  de- 
formity or  weakness  is  likely  to  be  exaggerated.  In  younger  subjects 
such  symptoms  are  far  less  marked,  or  are  absent.  In  the  cases  in 
which  the  deformity  is  extreme,  symptoms  due  to  interference  with 
the  respiratory  and  circulatory  apparatus,  or  caused  by  the  displace- 
ment of  the  abdominal  organs,  may  be  present.  These  are,  however, 
rather  unusual. 

Diagnosis.  Posture. — Lateral  curvature  of  the  spine  is  a  sim- 
ple deformity  unaccompanied  by  the  symptoms  of  disease.  When  the 
patient  stands  with  the  back  and  hips  bare,  the  inclination  of  the  body 
to  one  or  the  other  side  and  the  general  want  of  symmetry,  are  usually 
apparent,  even  in  the  earliest  stage  of  the  affection.  For,  as  has  been 
stated,  the  habitual  assumption  of  a  certain  posture  precedes  fixed 
changes  in  and  about  the  spine,  and  this  posture  will  appear  when  the 
patient  is  asked  to  stand  in  the  usual  manner.  If  the  inclination  of 
the  body  is  toward  the  left  (Fig.  69),  the  left  arm  will  hang  in  close 
apposition  to  its  lateral  border,  while  on  the  right  side  an  interval 
will  appear  between  the  arm  and  the  trunk.  If  there  be  a  slight  lum- 
bar curve  to  the  left  (Fig.  71),  the  right  iliac  crest  will  be  accentuated. 

1  Medical  Eecord,  Dec.  16,  1893. 


142  LATERAL   CURVATURE  OF  THE  SPINE. 

The  curvature  in  the  dorsal  region  makes  one  shoulder  higher  than 
the  other  (Fig.  83),  the  scapula  on  the  aifected  side  projects  and  the 
distance  between  its  posterior  border  and  the  median  line  is  increased. 
Rotation  of  the  spine  is  shown  by  the  fullness  or  projection  of  one  side 
accompanied  by  a  corresponding  flatness  on  the  other.  This  is  more 
noticeable  when  the  patient  bends  the  body  forward  so  that  the  hori- 
zontal plane  of  the  back  is  brought  into  view.  (Fig.  70.)  Corre- 
sponding changes,  though  of  a  less  marked  degree,  appear  on  the  ante- 
rior surface  of  the  body,  for  example  the  apparent  diminution  in  the 
size  of  the  mamma  on  the  side  opposite  the  convexity  of  the  posterior 
curve  and  its  relative  depression  or  elevation  will  usually  attract 
attention. 

It  seems  probable  that  a  change  in  the  antero-posterior  contour  of 
the  spine  precedes,  in  many  instances,  the  lateral  deviation.  Thus  a 
general  droop  of  the  body  associated  with  round  shoulders  and  a  flat- 
tening of  the  chest,  may  be  regarded  as  a  predisposing  cause  or  an 
early  svmptom  of  more  serious  deformity. 

Mobility. — As  has  been  stated,  it  may  be  assumed  that  habitual 
posture  precedes  actual  deformity ;  habitual  posture  implies  disuse  of 
certain  other  attitudes  and  motions,  thus  limitation  of  the  normal  flexi- 
bilitv  of  the  spine  may  be  considered  as  one  of  the  earliest  signs  of 
progressive  deformity.  The  test  of  the  motion  of  the  diflerent  regions 
of  the  spine  is  therefore  a  necessary  part  of  the  examination.  To  test 
the  motion  in  the  lumbar  region,  one  fixes  the  pelvis  with  the  hands 
while  the  patient  sways  the  body  in  the  four  directions  and  rotates  it 
from  side  to  side.  It  is  suggested  by  Bradford  and  Lovett  that  direct 
lateral  flexibility  may  be  tested  by  placing  blocks  of  wood  under  one 
foot,  until  the  limit  of  flexion  is  reached,  as  shown  by  the  inability  of 
the  patient  to  hold  the  elevated  limb  in  the  extended  position.  The  ex- 
periment is  then  repeated  on  the  opposite  side.  The  flexibility  of  the 
upper  part  of  the  trunk  may  be  tested  by  fixing  the  part  below  with 
the  hands  while  the  patient  flexes,  extends  and  rotates  the  body.  It 
is  important  also  to  test  the  range  of  motion  at  the  shoulder  joints. 
The  normal  individual  should  be  able  to  hold  the  arms  extended  di- 
rectly above  the  head  without  increasing  the  lumbar  lordosis.  In 
many  instances,  however,  it  will  be  found  that  there  is  a  marked  re- 
striction of  this  motion,  in  fact  such  restriction  is  almost  always  an  ac- 
companiment of  so-called  round  shoulders. 

The  height  and  weight,  the  circumference  and  the  expansion  of  the 
chest  should  be  investigated,  and  a  test  of  the  muscular  strength,  not 
only  of  the  muscles  of  the  trunk  but  of  the  members  as  well,  is  of  ad- 
vantage as  throwing  light  on  the  etiology  and  indicating  the  general 
line  of  treatment. 

Record. — The  most  reliable  of  the  graphic  records  to  be  used  in 
connection  with  the  history  are  photographs.  The  patient  may  stand 
behmd  a  thread  screen  (Fig.  86)  in  the  habitual  attitude.  The  spin- 
ous processes,  the  iliac  crests  and  the  angles  of  the  scapulae  having 
been  marked  with  the  flesh  pencil,  the  exact  amount  of  lateral  devia- 


PROGNOSIS. 


143 


Fig. 


tion  of  the  trunk  will  be  shown.     The  rotation  may  be  indicated  also 
by  photdgraphing  the  patient  in  the  recumbent  posture. 

The  rotation  of  the  spine  is  the  most  important  indication  of  de- 
formity. This  may  be  recorded  with  sufficient  accuracy  by  taking 
direct  tracings  of  half  the  trunk  at 
fixed  points  by  means  of  a  lead  or 
zinc  tape  while  the  patient  lies  in 
the  recumbent  posture. 

At  the  Hospital  for  Ruptured 
and  Crippled,  the  shadow  of  the 
trunk  cast  by  an  electric  light  at 
a  fixed  distance  is  traced  upon  a 
large  sheet  of  paper.  Upon  this 
outline  the  position  of  the  more  im- 
portant landmarks  is  indicated. 
The  degree  of  rotation  is  shown 
by  transverse  tracings  and  the  line 
of  the  spinous  processes  is  ascer- 
tained by  applying  a  broad  strip  of 
adhesive  plaster  to  the  back  upon 
which  the  tip  of  each  spinous  proc- 
ess is  marked. 

Prognosis. — In  the  development 
of  lateral  curvature  there  is  doubt- 
less a  preliminary  or  predisposing 
stage^  a  stage  of  progression  and  a 
stage  of  arrest.  All  deformities  of 
this  class  are  more  likely  to  progress 
during  the  growing  period.  They 
are  likely  to  become  stationary 
when  the  period  of  growth  is  com- 
pleted. Thus  the  prognosis  is  worse 
when  the  deformity  begins  at  an 
early  age  than  when  it  first  appears 
in  adolescence,  especially  if  treatment  is  neglected  or  if  it  is  inefficient. 
For  example,  some  of  the  most  extreme  cases  are  caused  by  rhachitis, 
in  which  the  deformity  appearing  in  infancy  or  early  childhood  in- 
creases with  the  growth  of  the  child. 

If  the  causes  of  the  deformity  are  such  that  they  operate  to  check 
the  equal  development  of  the  affected  part,  the  prognosis  is  even  more 
directly  influenced  by  the  age  of  the  patient.  For  example,  empyema, 
even  if  the  lung  is  irreparably  damaged,  does  not  cause  appreciable 
deformity  in  the  adult,  but  in  childhood  the  functional  activity  and  the 
growth  of  the  side  of  the  thorax  are  checked,  in  addition  to  the  direct 
effect  of  the  adhesions  and  contractions  due  to  the  disease,  thus  the 
deformity  is  likely  to  be  progressive  in  spite  of  the  treatment.  The 
same  is  true  of  paralytic  deformity.  In  the  ordinary  type  of  lateral 
curvature  in  the  adolescent  girl,  the  prognosis  is  influenced  of  course, 


The  thread  screen.    From  the  Bonton  (  hildreii's 
Hospital  Report. 


/    i 


144:  LATERAL   CURVATURE  OF  THE  SPINE. 

by  the  general  condition  of  the  patient  and  by  the  character  of  the 
occupation.  As  far  as  the  local  deformity  is  concerned,  the  prognosis 
as  regards  improvement  or  cure  depends  in  great  degree  upon  the  fixed 
changes  that  have  taken  place,  and  upon  the  degree  of  voluntary  and 
involuntary  rectification  that  is  possible.  In  some  instances  the  dis- 
tortion of  the  body  as  apparent  in  the  habitual  posture  may  be  con- 
siderable, yet  the  fixed  deformity  may  be  very  slight,  while  in  other 
instances  the  fixed  rotation  of  the  spine  may  be  marked  although  the 
lateral  distortion  is  hardly  noticeable. 

A  single  curve  is  more  amenable  to  treatment  than  is  a  double  or 
triple  distortion,  because  it  indicates  an  earlier  stage  of  deformity  and 
because  the  treatment  may  be  more  effective  when  applied  to  one  de- 
formity than  to  several.  If,  however,  the  single  curve  is  fixed,  the 
appearance  of  a  secondary  or  compensatory  curve  at  another  part  of 
the  spine  is  probable,  in  spite  of  preventive  treatment. 

In  the  majority  of  cases,  as  has  been  stated,  fixed  deformity  of  the 
spine  is  already  present  when  the  patient  is  brought  for  treatment. 
This  fixed  deformity  might  be  overcome  doubtless  in  certain  cases,  and 
complete  cure  might  be  obtained,  were  all  the  conditions  favorable. 
But  in  the  ordinary  sense  a  cure  means  the  relief  of  symptoms,  the 
checking  of  the  progress  of  the  deformity  and  the  restoration  of  the 
general  symmetry  of  the  trunk.  Such  a  cure  may  be  obtained  in  most 
instances.  The  deformity  of  the  spine  becomes  symmetrically  divided 
on  either  side  of  the  median  line,  the  changes  incident  to  maturity, 
particularly  the  increased  amount  of  adipose  tissue,  serve  to  conceal 
the  irregularities  of  the  outline,  and  the  history  of  the  distortion  is 
completed. 

In  certain  instances,  particularly  in  well-marked  cases,  the  deform- 
ity may  increase  in  adult  life  and  even  in  old  age  ;  and  in  this  class 
also  the  symptoms  of  discomfort  and  actual  pain  may  be  troublesome 
throughout  life,  especially  in  the  overworked  and  debilitated  class. 
The  symptoms  directly  incident  to  the  compression  and  distortion  of 
the  internal  organs,  have  been  mentioned. 

The  great  majority  of  cases  that  develop  or  that  are  discovered  in 
adolescence,  progress  for  a  time  and  come  to  an  end  on  the  cessation  ot 
growth,  causing  finally  no  symptoms  other  than  the  loss  of  symmetry 
that  may  be  more  or  less  perfectly  concealed  by  the  art  of  the  dress- 
maker and  by  the  corset. 

It  would  appear  then  that  lateral  curvature  of  the  spine  is  always 
of  sufficient  gravity  to  merit  treatment  and  supervision  until  its  cure 
or  arrest  is  assured.  If  its  discovery  leads  to  active  efforts  to  improve 
the  general  condition  and  to  avoid  unhealthful  influences,  it  may  even 
be  of  benefit  to  the  patient. 

Lateral  curvature  in  a  young  child  is  of  far  greater  importance  be- 
cause of  the  probability  of  an  increase  of  deformity.  Extreme  de- 
formity is  always  a  source  of  weakness  and  usually  of  discomfort  to  the 
patient.  Incipient  deformity  may  be  cured  and  cure  is  not  impossible 
even  when  deformity  is  more  advanced,  but  in  this  more  than  in  any 


RECAPITULATION.  145 

other  postural  deformity,  absolute  cure  implies  early  diagnosis  and 
prevention,  rather  than  the  correction  of  fixed  distortion. 

Recapitulation. — It  seems  probable  that  in  the  ordinary  type  of  lat- 
eral curvature  of  the  spine,  the  first  step  is  a  change  in  the  relation  of 
the  bodies  of  the  vertebrae  to  one  another ;  that  a  persistent  lateral  in- 
clination and  rotation  of  the  anterior  part  of  the  column  precedes  the 
lateral  inclination  of  the  trunk  which  first  calls  attention  to  the  de- 
formity. This  postural  distortion  becomes  fixed  by  accommodative 
changes  in  the  muscles  and  other  tissues  about  the  spine,  and  finally 
it  is  confirmed  by  changes  in  the  shape  of  the  vertebral  bodies  and  by 
the  general  changes  in  the  trunk  as  a  whole.  Thus  if  one  might  ob- 
serve the  inception  and  development  of  lateral  curvature  of  the  com- 
mon type  he  would  note,  first,  that  the  trunk  was  more  often  flexed 
to  one  side  than  to  the  other,  and  that  this  attitude  gradually  became 
habitual.  •  Lateral  inclination  of  the  trunk  necessitates  of  course  lateral 
deviation  and  rotation  of  the  bodies  of  the  vertebrae  and  the  habitual 
assumption  of  such  a  posture  implies  disuse  of  other  postures  and  thus 
disuse  of  normal  motion. 

Disuse  of  motion  in  any  direction  is  followed  by  diminished  power 
in  the  inactive  muscles,  and  as  has  been  stated  habitual  deformity  is  fol- 
lowed by  accommodative  changes  to  a  greater  or  less  degree  in  the 
various  tissues  whose  functions  have  been  changed  or  modified. 

Thus  the  progress  of  the  deformity  would  be  shown  : 

1.  By  the  habitual  assumption  of  an  attitude  simulating  deformity. 

2.  By  limitation  of  motion  in  the  directions  opposed  to  the  habitual 
attitudes. 

3.  By  fixed  lateral  deviation  of  the  spine  accompanied  by  rotation  or 
twisting  of  the  column. 

One  rarely  has  the  opportunity  to  note  the  development  of  lateral 
curvature  and  when  patients  are  brought  for  treatment  fixed  deformity 
is  usually  present.  It  is  extremely  difficult  to  entirely  overcome  fixed 
distortion,  while  it  is  comparatively  easy  to  correct  simple  postural 
deformity  in  which  the  secondary  changes  are  absent  or  but  slightly 
advanced.  On  this  account  it  is  customary  to  divide  lateral  curvature 
into  two  classes,  the  true  and  the  false,  or  to  speak  of  rotary  lateral 
curvature  as  distinct  from  lateral  curvature.  Thus  the  term  true  or 
rotary  curvature  would  be  limited  to  those  cases  in  which  the  changes 
are  fixed  and  in  which  cure  is  practically  impossible,  while  false  or 
simple  or  postural  lateral  curvature  would  include  the  early  or  cur- 
able class.  But  as  the  two  forms  are  simply  stages  in  the  same  proc- 
ess it  would  seem  preferable  to  speak  of  the  incipient  and  the  later 
stages  of  lateral  curvature,  or  of  reducible  or  irreducible  deformity, 
the  distinctions  that  are  made  in  classifying  distortions  of  similar 
origin  elsewhere. 

This  point  of  view  is  of  advantage  because  it  relieves  the  subject  of 

much  of  the  obscurity  that  has  resulted  from  this  arbitrary  division. 

It  emphasizes  the  fact  also  that  the  habitual  assumption  of  an  improper 

attitude  that  simulates  deformity  is  the  first  step  toward  permanent  dis- 

10 


146 


LATERAL  CURVATURE  OF  THE  SPINE. 


tortion,  particularly  in  individuals  who  are  by  inheritance  or  by  con- 
stitutional tendency  or  by  occupation  predisposed  to  such  deformity. 

The  Prevention  of  Deformity. — Prevention  would  include  the 
avoidance  of  all  the  predisposing  or  exciting  causes  of  weakness  as 
well  as  of  deformity.     These  it  is  hardly  necessary  to  enumerate. 

The  first  and  most  important  preventive  measure  is  the  discovery 
of  deformity  or  the  tendency  to  deformity,  at  a  time  when  it  may  be 
checked  or  cured.  To  discover  deformity  at  this  period  of  its  devel- 
opment, one  must  look  for  it,  and  deformity  in  this  sense  would  in- 
clude not  only  fixed  distortion,  but  improper  attitudes  and  postures  of 
every  variety  as  well. 

The  importance  of  the  attitude  which  is  habitually  assumed  during 
occupation  has  been  mentioned.  Therefore,  the  provision  of  proper 
desks  and  seats  for  school  children  is  a  very  essential  part  of  preventive 
treatment. 

The  seat  of  the  chair  should  be  deep  enough  to  support  the  thighs, 
yet  it  should  not  interfere  with  flexion  at  the  knees.  It  should  be  of 
such  height  as  to  allow  the  feet  to  rest  firmly  on  the  floor,  and  it 


Fig.  87. 


Adjustable  school  desks  and  seats.    Schelber  and  Klein.    (R^dakd.) 

should  be  inclined  slightly  backward.  The  back  of  the  chair  should 
extend  to  about  the  level  of  the  shoulders,  it  should  be  inclined 
slightly  backward,  but  arched  somewhat  forward  in  the  lumbar  region 
in  order  to  conform  to  the  normal  lordosis  when  the  child  sits  in  the 
erect  posture.  The  desk  should  be  as  close  to  the  body  as  is  possible, 
so  that  the  child  need  not  lean  far  forward  when  reading  or  writing. 
The  height  of  the  desk  should  be  slightly  less  than  the  level  of  the 
elbows  when  the  child  sits  erect,  and  the  inclination  should  be  suffi- 
cient to  hold  the  book  at  the  proper  distance  from  the  eyes.  The 
vertical  handwriting  is  of  advantage  in  that  the  children  are  taught 
to  face  the  desk  squarely,  as  contrasted  with  the  lateral  twist  of  the 
body,  the  usual  attitude  for  writing.     (Figs.  87  and  88.) 


PRINCIPLES  OF  TREATMENT. 


147 


Treatment. — The  treatment  of  rotary  lateral  curvature  of  the  spine 
does  not  differ  in  principle  from  the  treatment  of  any  other  weakness 
or  deformity,  but  the  application  of  this  principle  is  much  more  diffi- 
cult here  than  elsewhere,  and  the  results  are  far  less  definite  and  satis- 
factory. This  explains  doubtless  the  apparently  opposing  theories  and 
methods  of  treatment  that  are  still  advocated. 

A  brief  account  then  of  the  rules  of  treatment  as  applied  to  weak- 
ness in  general  and  of  the  exceptions  that  must  be  made  in  their  appli- 
cation to  curvature  of  the  spine  may  be  illustrated  by  comparing  this 
deformity  with  another  of  similar  causation. 

One  may  take  for  comparison  the  weak  foot,  since  the  foot  corre- 
sponds more  nearly  to  the  spine  than  does  a  simple  joint,  because  of  the 
number  of  bones  of  which  it  is 
made  up.  In  the  treatment  of 
the  weak  foot  one  must  first  over- 
come all  restrictions  to  passive 
motion,  even  by  force  if  this  be 
necessary.  One  next  endeavors 
to  strengthen  the  muscles  that 
support  the  foot,  by  appropri- 
ate exercises,  particularly  those 
whose  action  is  opposed  to  the 
habitual  deformity.  The  avoid- 
ance of  improper  attitudes  and  of 
over-fatigue  that  favor  deformity 
is  also  essential.  Finally,  if  per- 
sistent deformity  makes  it  evi- 
dent that  the  voluntary  or  natural 
efforts  of  the  patient  are  ineffi- 
cient, a  brace  is  employed  to  sup- 
port the  foot  in  proper  position 
in  order  to  aid  the  weakened 
muscles  and  to  hold  the  joints  in 
the  normal  position  in  which 
they  may  work  to  advantage. 
Under  these  conditions  one 
would  expect  an  immediate  relief 
of  discomfort  and  a  progressive  transformation  of  the  internal  struc- 
ture of  the  foot,  which  in  favorable  cases  would  lead  to  complete  cure 
of  the  deformity  and  of  the  weakness  as  well. 

The  principles  of  the  treatment  of  any  variety  of  weakness  not  di- 
rectly induced  by  disease  are  then  : 

1.  To  overcome  all  restriction  to  passive  motion. 

2.  To  strengthen  the  weakened  muscles,  especially  those  whose  ac- 
tion is  opposed  to  habitual  deformity. 

3.  To  insist  on  the  avoidance  of  over-fatigue  and  improper  postures. 

4.  To  support  the  weak  part,  if  necessary,  by  a  brace. 

In  applying  these  principles  to  the  treatment  of  the  distorted  spine 


Adjustable  school  seat.     (Miller  and  Stone.) 


148  LATERAL   CURVATURE  OF  THE  SPINE. 

the  first  step,  the  removal  of  restriction  to  passive  motion  in  all  direc- 
tions, may  be  accomplished  unless  the  deformity  is  of  long  standing, 
but  this  is  difficult  because  of  the  variety  of  muscles  and  other 
tissues  that  may  have  become  involved,  and  because  the  bodies  of  the 
vertebrse  lying  within  the  trunk,  of  which  the  distortion  is  always 
greater  than  the  spinous  processes,  can  be  only  indirectly  affected  by 
voluntary  or  by  passive  movements.  The  cultivation  of  the  muscular 
system  and  particularly  of  those  muscles  whose  action  is  opposed  to 
the  habitual  deformity,  is  the  second  indication  in  treatment.  As  ap- 
plied to  the  treatment  of  the  weak  foot  in  which  the  adductor  and  ex- 
tensor muscles  are  at  fault,  this  treatment  is  simple,  but  as  applied  to 
the  trunk  it  is  difficult  because  there  are  in  nearly  all  developed  cases  two 
curves,  the  one  primary  and  the  other  secondary  ;  in  direction  directly 
opposed  to  one  another.  These  opposite  deformities  are  supplied  in 
great  part  by  the  same  muscles  and  it  is  difficult  to  straighten  the  con- 
vexity of  one  curve  without  at  the  same  time  increasing  the  concavity 
of  the  other.  The  third  principle  in  treatment  is  the  avoidance  of 
predisposing  attitudes  and  of  overwork.  This  again  may  be  more 
easily  applied  to  the  treatment  of  the  weak  foot ;  first  because  it  is 
relieved  from  strain  when  the  sitting  posture  is  assumed  and  because 
active  use,  as  in  walking,  may  be  utilized  as  an  exercise  for  strengthen- 
ing the  muscles.  But  the  muscles  of  the  trunk  are  not  exercised  to 
any  extent  in  ordinary  walking,  which  is  for  many  individuals  the 
only  form  of  activity,  nor  is  the  spine  relieved  from  weight  when  the 
patient  is  seated.  On  the  contrary  it  is  in  this  restful  attitude  that 
the  deformities  of  the  spine  are  usually  most  marked.  Thus  only  in 
the  recumbent  attitude  is  the  spine  entirely  relieved  from  strain,  and 
even  at  such  times  the  deformities  may  be  favored  by  the  habitual  atti- 
tudes of  the  patient. 

Support  of  the  weakened  part  by  braces.  The  weak  foot  can  be 
supported  by  a  brace  which  in  no  way  interferes  with  its  activity,  but 
which  on  the  contrary  makes  movements  free  and  normal  by  holding 
the  bones  in  their  proper  relation  to  one  another.  But  in  the  treat- 
ment of  the  spine  the  conditions  are  quite  different,  since  the  back  can- 
not be  supported  without  at  the  same  time  practically  fixing  it  in  one 
position,  restraining  its  normal  motion  and  compressing  the  muscles  of 
the  trunk.  In  other  words  the  action  of  the  support  and  the  action 
of  the  muscles,  instead  of  aiding  one  another,  are  almost  directly  op- 
posed to  one  another ;  and  finally  no  brace  applied  to  the  trunk  is 
efficient,  for  while  it  may  prevent  the  excessive  lateral  deformity  it  can 
exercise  no  direct  action  in  overcoming  the  rotation  of  the  spinal  column. ' 
For  these  reasons  braces  except  as  temporary  supports  in  cases  under 
corrective  treatment  and  in  the  hopeless  class,  are  less  in  favor  than  in 
former  times. 

This  comparative  method  of  exposition  has  been  adopted  in  order 
to  demonstrate  the  fact  that  it  is  not  the  difficulty  in  formulating  prin- 
ciples but  the  difficulty  in  applying  them  that  makes  the  therapeutics  of 
rotary  lateral  curvature  of  the  spine  perplexing.     It  is  only  by  recog- 


PRINCIPLES  OF  TREATMENT.  149 

nizing  the  limitations  of  all  systems  of  treatment  as  applied  to  this 
particular  deformity  and  the  necessity  for  selection  and  combination 
of  methods  that  may  be  applicable  to  the  particular  case  under  treat- 
ment that  one  may  arrive  at  satisfactory  conclusions.  Thus  methods 
must  be  modified  by  the  age  of  the  patient  and  by  a  variety  of  other 
circumstances. 

For  example,  in  the  treatment  of  rhachitic  scoliosis  in  a  young  child 
one  cannot  count  upon  the  voluntary  assistance  of  the  patient,  therefore 
treatment  by  simple  gymnastic  exercises  is  impracticable.  In  this  class 
of  cases  forcible  correction  of  the  deformity  and  retention  by  the  use  of 
apparatus,  combined  with  massage,  and  the  removal  of  superincumbent 
weight,  would  be  the  treatment  of  selection ;  for  at  this  age  the  trunk 
is  flexible  and  the  deformity  may  be  overcome,  in  part  at  least,  by 
forcible  manipulation.  By  progressive  reduction  of  the  distortion, 
followed  by  fixation  of  the  trunk  in  the  improved  position  one  may 
expect  at  this  period  of  rapid  growth  to  induce  a  transformation  of 
the  deformed  vertebral  bodies  to  an  approximation  at  least  of  the  nor- 
mal. In  this  class  of  cases  the  possibility  of  correcting  the  underlying 
deformity  of  the  bones  which  must  almost  inevitably  increase  with  the 
growth  of  the  patient  would  quite  outweigh  the  disadvantage  of  de- 
priving the  muscles  of  their  normal  stimulus  during  the  corrective 
period  of  treatment. 

In  the  ordinary  type  of  scoliosis  in  older  subjects,  particularly  if  the 
distortion  is  moderate  in  degree  and  the  changes  in  the  bones  but  slight, 
one  would  expect  to  attain  the  best  result  by  gymnastic  training  and 
by  regulation  of  the  postures. 

The  advisability  of  a  change  of  occupation  has  been  mentioned.  It 
is  probable  that  if  the  patient  with  incipient  or  even  pronounced  curva- 
ture of  the  spine  were  removed  from  school,  were  transferred  to  the 
country  where  during  the  succeeding  years  of  childhood  and  adoles- 
cence much  of  the  time  might  be  passed  in  active  exercise  in  the  open 
air,  the  final  result  Avould  compare  very  favorably  with  that  attained 
by  active  treatment  under  less  favorable  surroundings.  Such  complete 
change  of  occupation  and  scene  is  of  course  impracticable  in  most  in- 
stances. Lateral  curvature  of  the  spine  is  not  a  serious  disease,  it 
is  simply  an  insidious  distortion  which  rarely  causes  more  than  com- 
paratively slight  discomfort.  It  is  usually  overlooked  in  the  incipient 
stage  when  it  might  be  checked  or  cured,  and  when  the  deformity 
finally  attracts  attention  it  is  usually  no  longer  amenable  to  correction. 
Under  these  circumstances,  with  the  uncertainty  that  exists  as  to  the 
ultimate  prognosis,  the  tediousness  of  treatment  which  cannot  offer  the 
assurance  of  definite  cure,  it  is  not  strange  that  the  affection  is  not  one  for 
the  treatment  of  which  any  considerable  sacrifice  is  considered  essential. 

A  third  class  of  cases  would  include  the  fixed  deformity  in  older 
subjects,  many  of  whom  are  obliged  to  assume  in  their  occupations  atti- 
tudes that  predispose  to  deformity.  In  this  class  the  use  of  a  support 
to  relieve  discomfort  and  to  prevent  exaggerated  distortion,  may  be 
indicated. 


150  LATERAL   CURVATURE  OF  THE  SPINE. 

Thus  there  are  three  classes  or  types  of  scoliosis  in  which  distinct 
methods  of  treatment  may  be  indicated. 

1.  Curvatures  in  very  young  children,  in  which  forcible  correction 
and  fixation  would  be  the  preliminary  treatment,  in  the  hope  of  cor- 
recting the  deformity  of  the  bones  and  curing  the  distortion. 

2.  The  milder  degrees  of  deformity  for  which  treatment  by  exercises 
and  if  possible  by  favoring  postures  is  the  treatment  of  selection. 

3.  The  third  class  would  include  fixed  deformity  in  older  subjects, 
as  well  as  those  cases  caused  by  disease  ;  as  for  example  by  paralysis,  by 
empyema  and  the  like,  for  which  constant  support  might  be  indicated. 

As  a  rule,  however,  no  such  distinction  can  be  drawn.  The  treat- 
ment by  exercises  and  by  postures  applies  to  all  cases  except  in  very 
early  childhood,  while  support  is  indicated  in  a  far  more  limited  class. 

Posture  and  Exercises. — Whatever  may  have  been  the  original 
cause  of  the  distortion  of  the  spine  and  whatever  may  be  its  degree  it 
is  more  marked  when  the  patient  is  fatigued.  Fatigue  in  the  normal 
individual  is  shown  by  the  increase  in  the  normal  antero-posterior 
curves  ;  fatigue  in  the  deformed  subject  causes  an  increase  in  the  path- 
ological curves.  It  requires  far  more  muscular  effort  to  hold  the 
deformed  spine  in  the  best  possible  attitude  than  to  hold  the  normal 
spine  in  the  erect  posture.  Motion  in  the  normal  spine  is  as  free  in  one 
direction  as  in  another  and  it  simply  requires  a  proper  balancing  of 
the  muscular  force  to  hold  it  in  the  median  line.  Under  the  influence 
of  fatigue  it  has  no  more  inclination  toward  one  side  than  the  other 
unless  the  occupation  or  the  attitude  of  the  patient  influences  it.  But 
when  there  is  a  fixed  deformity,  to  overcome  which,  even  in  part, 
requires  the  conscious  effort  of  the  patient,  it  is  evident  that  on  the 
relaxation  of  this  effort  the  spine  will  sink  back  into  the  habitual 
posture.  The  more  confirmed  the  deformity  the  greater  must  be  the 
effort  to  overcome  it,  and  the  more  rapidly  will  fatigue  be  manifest. 
Fatigue,  or  rather  the  relaxation  of  conscious  muscular  effort,  is  fa- 
vored by  attitudes  that  do  not  require  the  balancing  action  of  the 
muscles.  For  example,  the  sitting  posture  during  school  hours  favors 
deformity,  while  the  constant  alternation  of  postures  in  work  or  play 
that  requires  muscular  activity  opposes  it.  Thus  the  selection  of  oc- 
cupations, or  at  least  the  restriction  of  the  time  passed  in  inactive 
postures,  is  an  essential  part  of  treatment. 

As  improper  attitudes  are  favored  by  weakness  of  muscles  and  as 
the  maintenance  of  the  best  possible  position  requires  a  greater  expen- 
diture of  muscular  force  than  is  required  in  the  normal  individual, 
the  strengthening  of  all  the  muscles  of  the  body,  and  particularly  of 
those  of  the  back,  by  gymnastic  exercises,  even  beyond  the  normal 
standard,  is  the  most  important  indication  in  treatment. 

One  of  the  most  effective  systems  of  treatment  of  lateral  curvature 
is  that  advocated  by  Teschner,  of  New  York.  On  the  theory  that 
lateral  curvature  is  induced  or  that  its  development  is  favored  by  a 
general  lack  of  muscular  strength  and  lack  of  muscular  control  and 
codrdination  Teschner  urges  the  necessity  of  the  systematic  cultivation 


EXERCISES. 


151 


of  all  the  muscles  of  the  body  as  well  as  those  of  the  trunk,  the  part 
particularly  at  fault.  He  also  insists  upon  the  importance  of  exercis- 
ing each  muscular  group  to  the  point  of  fatigue  on  the  theory  that  a 
muscle  cannot  be  developed  to  its  full  capacity  unless  it  is  thoroughly 
fatigued  by  uninterrupted  automatic  contractions  and  relaxations.  The 
term  automatic  implies  that  the  patient  shall  be  so  thoroughly  trained 
in  the  rhythmical  movements  that  they  require  no  thought  for  their 
performance.  Thus  ease  and  grace  may  replace  awkwardness  and  in- 
coordination. 

The  system  advocated  by  Teschner  is  modified  from  one  taught  by 
Attilla,  a  "  trainer  of  strong  men."  It  consists  of  a  series  of  exer- 
cises with  light  dumb-bells  and  it  is  followed  by  so-called  heavy  work. 


Fig. 


Fia.  90. 


Fig.  91. 


The  exercises  are  designed  for  systematic  cultivation  of  all  the  mus- 
cles of  the  body,  the  heavy  work  more  directly  for  the  correction  of 
the  deformity  of  the  spine. 

'lr  General  Exercises. — The  exercises  should  be  performed  before  a  mir- 
ror, the  patient  being  clad  in  a  close-fitting  rowing  suit  so  that  the  atti- 
tudes may  be  constantly  observed  by  the  patient  and  by  the  instructor. 
The  greatest  attention  is  paid  to  the  perfection  of  the  alternating 
movements  of  the  limbs  in  order  that  they  may  become  in  time  purely 
automatic  in  character.  During  the  performance  of  the  exercises  the 
patient  holds  himself  in  the  best  possible  position. 

These  exercises  were  described  and  illustrated  by  Teschner  in  the 
Annals  of  8urgery  for  August,  1895,  from  which  they  are,  with  his  per- 
mission, reproduced. 

"  A  pair  of  dumb-bells,  weighing  from  one-half  to  five  pounds  each, 
according  to  the  ability  of  the  patient,  is  used  in  a  series  of  twenty-six 
exercises. 


152 


LATERAL   CURVATURE  OF  THE  SPINE. 


The  Exercises. — The  patient  stands  erect,  the  heels  together,  the 
toes  apart,  the  knees  thoroughly  extended,  the  abdomen  retracted,  the 


Fig.  93. 


Q:r;:i: 


chest  high,  the  head  well  poised,  and  the  patient  looking  intently  and 
sharply  into  his  or  her  own  eyes  in  the  mirror,  the  lips  being  evenly, 
but  not  too  firmly,  closed,  and  the  facial  muscles  in  repose.     The  pa- 


FiG.  94. 


Fig.  95. 


tient  should  breathe  easily  and  regularly  while  exercising.     (Figs.  89 
and  90.) 


EXERCISES. 


153 


"  1.   The  upper  extremities  are  fully  extended  downward,  the  fore- 
arms supinated,  the  elbows  remaining  close  to  the  sides  of  the  body, 
and  the  upper  arms  being  fixed  ;  the  fore- 
arms are  alternately  and  automatically  fully  Fig.  97. 


Fig.  96. 


flexed  and  extended,  the  wrists  and  entire  body  being  fixed  and  im- 
movable.    Twenty  to  fifty  times.     (Fig.  91.) 

"  2.  The  same  position  and  exercise,  except  that  the  forearms  are 


Fig. 


Fig.  99. 


154 


LATERAL   CURVATURE  OF  THE  SPINE. 


fully  pronated,  and  remain  so  during  alternate  flexion  and  extension. 
Twenty  to  fifty  times.     (Fig.  92.) 

"  3.  Both  bells  over  the  shoulders,  the  arms  abducted  at  right  angles 
to  the  body  and  in  the  same  vertical  and  horizontal  planes,  the  fore- 
arms fully  flexed  upon  the  arms,  and  the  wrists  fully  flexed  upon  the 
forearms.  The  forearms  and  wrists  are  then  alternately  and  automat- 
ically extended  and  flexed.     Ten  to  twenty  times.     (Fig.  93.) 

"  4.  The  same  position  and  exercise,  except  that  both  upper  extrem- 
ities are  flexed  and  extended  at  the  same  time.  Five  to  fifteen  times. 
(Fig.  94.) 

"  5.  Both  upper  extremities  fully  extended  forward  on  a  level  with 
the  shoulders,  the  dorsum  of  the  hands  outward.  They  are  then 
fully  and  forcibly  abducted  on  a  horizontal  plane,  the  patient  at  the 
same  time  raising  body  upon  the  toes,  and  are  then  permitted  to  re- 


FiG.  100. 


Fig.  101. 


cede  to  the  original  position,  the  body  resting  on  the  toes  and  heels, 
the  elbows  and  wrists  still  rigid,  the  bells  not  being  permitted  to 
touch  as  they  approximate  each  other.  Five  to  ten  times.  (Figs.  95 
and  96.) 

"  6.  Bells  in  the  position  of  exercises  No.  3  and  No.  4.  The  arms 
are  fullv  extended  alternately  above  the  head.  Ten  to  twenty  times. 
(Fig.  97.) 

"  7.  Bells  in  front  of  the  thighs,  forearms  pronated,  and  bells  alter- 
nately raised  to  the  level  of  the  shoulders,  the  elbows  and  wrists  be- 
ing fixed.     Ten  to  twenty  times.     (Fig.  98.) 

"  8.  The  arms  abducted  at  right  angles  to  the  body,  the  bells  rotated 
rapidly  and  forcibly  forward  and   backward,  the  elbows   being  fixed.  ^ 
Five  to  ten  times.     (Fig.  99.) 


EXERCISES. 


155 


"9.  The  arms  abducted  at  right  angles  to  the  body,  the  thumbs  upon 
one  ball  of  each  bell,  the  hands  circumducted  forward  from  above 
downward,  the  ball  upon  which  the  thumbs  rest  describing  circles,  the 
elbows  and  shoulders  being  fixed.     Five  to  ten  times.     (Fig.  100.) 

''10.  The  same  as  No.  9,  the  hands  being  circumducted  backward. 
Five  to  ten  times.     (Fig.  100.) 

"11.  The  bells  to  the  side.  Right  face  upon  left  heel,  then  placing 
the  left  foot  at  right  angles  to  right  foot  opposite  the  arch,  the  knees 
slightly  flexed,  the  right  hand  at  waist-line  against  the  body,  the  bell 

Fig.  103. 


Fig.  102 


being  perpendicular.  Second  part  of  motion  :  strike  from  the  shoulder 
to  level  of  the  face,  advancing  a  step  upon  the  left  foot,  rapidly  ex- 
tending the  right  thigh  and  leg,  the  right  foot  being  fixed  upon  the 
floor,  and  quickly  back  to  position.  Ten  to  fifteen  times.  (Figs.  101 
and  102.) 

"12.  Exactly  the  reverse  of  No.  11.     Ten  to  fifteen  times. 

"13.  Bells  extending  above  the  head,  palmar  surfaces  looking  for- 
ward, bending  down  to  the  floor,  the  knees  remaining  extended,  and 
return.     Five  to  fifteen  times.     (Figs.  103  and  104.) 

"  14.  Bells  downward  at  the  sides,  raising  and  dropping  the  shoul- 
ders.    Ten  to  twenty  times.     (Fig.  105.) 

"  15.  Bells  downward  at  the  sides,  flexing  the  spine  laterally,  first  to 
the  right  and  then  to  the  left.     Ten  to  twenty  times.     (Fig.  106.) 

"  16.  Both  arms  extended  forward  to  about  forty-five  degrees  and  ab- 
ducted at  about  the  same  angle,  then  forcibly  crossed  in  front  of  the 


156 


LATERAL   CURVATURE  OF  THE  SPINE. 


chest,  causing  the  pectoral  muscles  to  contract  vigorously,  the  elbows 
and  wrists  being  fixed,  and  then  back  to  the  original  position.  Five 
to  twenty  times,  alternating  the  right  and  left  hands  above.  (Fig.  107.) 


Fig.  106. 


•*\ 


"  17.  Bells  at  the  sides,  palmar  surfaces  looking  forward.  Extend 
arms  backward  in  a  vertical  plane  as  forcibly  as  possible,  holding  them 
rigid  in  the  fully  extended  position  for  a  few  moments,  and  then  re- 


FiG.  107. 


Fig.  K 


EXERCISES. 


157 


turning  the  bells  to  the  sides.  Five  to  fifteen  times.  (Figs.  108 
and  109;) 

"18.  Bells  to  the  sides.  Raise  the  body  upon  the  toes  and  sink  to 
original  position.     Ten  to  twenty  times.     (Fig.  110.) 

"  19.  Same  position.     Raise  the  toes  as  far  as  possible  from  the  floor, 


Fig.  109. 


Fig.  110. 


the  body  remaining  erect.     Ten  to  twenty  times.     (Fig.  111.) 

"  20.  Same  position.  The  patient  squats,  abducting  the  knees  and 
resting  upon  the  toes,  the  heels  being  raised,  the  trunk  perfectly  erect, 
then  resuming  first  position.     Five  to  twenty  times.     (Fig.  112.) 


Fig.  111. 


Fig.  112. 


158 


LATERAL   CURVATURE  OF  THE  SPINE. 


"21.  Same  position.  Standing  upon  left  foot.  Flexing  the  right 
thigh  to  a  right  angle  to  the  body  extending  the  knee  and  ankle  fully. 
The  patient  squats  on  the  left  ham,  the  left  heel  remaining  on  the  floor. 


Fig.  114. 


Fig.  113. 


and  then  resumes  the  first  position.     Two  to  five  times.     (Fig.  113.) 
"  22.  The  same  standing  upon  the  right  foot.     Two  to  five  times. 
"  23.  The  same  position.     Alternately  and  forcibly  flexing  the  thighs 


Fig.  115. 


Fig.  116. 


EXERCISES. 


159 


and  legs,  causing  the  knees  to  touch  the  shoulders.     Ten  to  twenty 
times.     (Fig.  114.) 

Fig.  117. 


..•-;r      \ 


"  24.  The  same  position  as  in  IS^o.  21,  extending  the  right  lower  ex- 
tremity, the  right  bell  inside  the  thigh,  the  right  foot  moved  in  a  cir- 


FiG.  118. 


Scoliosis  of  an  advanced  type  accompanied  by  dyspnoea  and  cyanosis.     (Teschner.  ) 


160  LATERAL   CURVATURE  OF  THE  SPINE. 

cle  on  a  horizontal  plane  to  complete  extension  backward,  and  resum- 
ing the  first  position.     Two  to  five  times.     (Figs.  115  and  116.) 

"  25.  The  same  as  No.  24,  standing  upon  the  right  foot.  Two  to 
five  times.      (Figs.  115  and  116.) 

"26.  Tlie  patient  lying  supine  upon  the  floor,  the  lower  extremities 
fully  extended,  the  bells  resting  upon  the  chest,  then  raising  the  trunk 

Fig.  119. 


The  same  patient  swinging  30-pound  bell,  showing  the  muscular  development.     (Teschnek.) 

to  the  sitting  position,  the  lower  extremities  remaining  extended,  and 
the  eyes  being  fixed  upon  the  ceiling,  and  returning  to  the  original 
position,  touching  the  back  of  the  head  only  on  the  floor,  thus  the 
hyperextension  of  the  spine  is  maintained.  Five  to  twenty  times. 
(Fig.  117.) 

"When  the  patient  has  become  proficient  in  these  exercises,  they 
should  be  done  at  home  every  morning  and  evening. 


EXERCISES. 


161 


"  The  Heavy  Work. — Bells,  weighing  from  five  to  eighty  pounds 
each,  and  steel  bars  and  bar-bells,  ^veighing  from  twenty-six  to  over 
one  hundred  and  eleven  pounds,  are  used  in  different  ways.  Bells  are 
pushed  from  the  shoulders  above  the  head  alternately  as  often  as  the 
patient  is  able.     (Fig.  119.)" 

"  The  patient  is  instructed  to  swing  a  heavy  bell  with  one  hand  from 


Fig.  120. 


Fig.  121. 


The  patient  pushing  25-pound  bells  ; 
the  right  arm  up.     (Teschner.  ) 


The  patient  pushing  25-pound  bells  ; 
the  left  arm  up.     (Teschner.) 


the  floor  above  the  head  and  down  again,  the  elbow  and  wrist  being 
fixed,  and  the  motion  repeated  as  often  as  possible  in  a  systematic 
manner ;  then  with  the  other  hand  the  same  number  of  times,  and 
later  with  both.  This  exerts  all  the  extensor  muscles  from  the  toes  to 
the  head  in  rapid  succession. 

"  When  a  heavy  bell  is  pushed  or  swung  above  the  head  on  the  side 
11 


162  LATERAL   CURVATURE  OF  THE  SPINE. 

opposite  the  scoliosis,  the  action  of  the  back  muscles,  to  sustain  the 
weight  and  equilibrium,  is  such  as  to  cause  the  curv^ed  spine  to  ap- 
proximate a  straight  line.  (Fig.  121.)  A  similar  result  is  produced 
when  a  heavy  weight  is  held  by  the  side  of  the  erect  body  on  the 
scoliotic  side,  the  arm  being  at  full  length. 

"  When  a  heavy  bar  is  raised  above  the  head  with  both  hands,  the 
patient  must  fix  the  eyes  upon  the  middle  of  the  bar  to  maintain  an 
equilibrium.  This  necessitates  the  bending  of  the  head  backward,  the 
straightening  and  hyperextending  of  the  spine,  and  consequently  cor- 
recting a  faulty  position  with  a  weight  superimposed.  The  heavier 
the  weight  put  above  the  head,  whether  with  one  hand  or  with  two,  the 
more  the  patient  must  exert  himself  or  herself  to  attain  and  maintain 
a  correct  or  an  improved  attitude  in  order  to  sustain  the  equilibrium. 
(By  an  improved  attitude  I  mean  the  greatest  amount  of  correction  of 
the  deviation  of  the  spine  that  the  fixation  of  a  deformity  will  allow 
of.)  Hence,  the  greater  the  weight,  the  more  forcible  the  actions  of 
the  muscles  become,  and  the  greater  the  temporary  reduction  of  a  de- 
formity. It  is  by  means  of  frequent  and  forcible  temporary  reductions 
of  deformities,  by  voluntary  muscular  action,  that  we  can  hope  to  im- 
prove, and  do  improve,  those  cases  which  are  amenable  to  any  form  of 
active  treatment. 

"  When  a  patient,  lying  supine  upon  the  floor,  raises  a  heavy  bar 
above  the  head  so  that  the  arms  are  perpendicular  to  the  floor,  the 
weight  of  the  bar,  the  position  and  weight  of  the  body,  and  the  action 
of  the  muscles  tend  to  broaden  the  entire  back  and  shoulders,  and  a 
slow  downward  movement  tends  to  widen  the  entire  chest,  and  most 
markedly  at  the  shoulders.  The  frequent  repetition  of  the  upward 
and  downward  movement  plays  an  important  part  in  the  rapid  devel- 
opment of  the  chest  and  back.  Pushing  the  bells  above  the  head, 
swinging  them  with  each  hand  separately  and  with  both  hands  to- 
gether, raising  a  bar  above  the  head,  standing  and  lying  down,  and  the 
exercises  before  enumerated,  constitute  one  day's  work. 

"  As  the  amount  of  work  performed  by  a  patient  depends  upon  the 
last  previous  record  of  that  patient,  that  record  must  be  improved  upon 
at  each  succeeding  visit,  unless  there  be  a  good  and  sufficient  reason  to 
the  contrary.  Most  patients  can  well  stand  three  treatments  a  week. 
(Vide  table.)  In  mild,  habitual  cases  improvement  in  deportment  is 
noticed  by  the  patients'  relatives  and  friends  and  by  the  patients  them- 
selves within  the  first  two  weeks.  In  those  cases  two  months'  treatment 
usually  suffices  to  effect  a  complete  cure.  In  the  more  severe  cases  it  is 
not  and  can  not  be  expected  to  attain  such  rapid  results,  but  a  certain 
appreciable  improvement  is  effected,  and  the  amount  of  improvement 
depends  upon  the  persistent  continuance  of  the  treatment.  When  there 
is  a  fixed  rotation  of  long  standing,  with  bony  and  ligamentous  changes, 
the  prospects  are  not  so  good  ;  but  even  in  those  cases  considerable  im- 
provement will  be  evident. 

"  Patients  are  not  permitted  to  wear  supports  of  any  kind,  not  even 
corsets.     They  should  not  exercise  until  at  least  two  hours  after  a 


EXERCISES. 


163 


meal,  nor  when  menstruating.  The  general  health  is  improved  by  the 
exercises  ;  the  patients  gain  in  height  and  weight.  The  girths  and 
breadth  measurements,  chest  depth,  strength  tests,  and  lung  capacity 
are  generally  increased,  and  the  depth  of  the  abdomen  is  usually  de- 
creased. In  some  cases,  especially  those  of  undersized  patients,  the  in- 
crease in  height  is  very  rapid,  and  it  is  certainly  more  than  the  increase 
by  ordinary  growth.  There  were  marked  cases  of  flat  foot  which  were 
benefited.  The  flat  feet  became  shorter  through  the  exercises  by  the 
increase  in  depth  of  the  inner  arches." 

Record  of  the  Work  Performed  by  a  Girl  14  Years  of  Age. 

(Teschner.) 


A 

d 

-  i 

o     1 

6 

Date. 

si 

1 
Pi 

2  a  "^ 

CO        < 

m 

s 

CO 

Fifty-Pound  Bar  Above 
THE  Head. 

Ph 

f^ 

Ph 

1895. 

Bells. 

Two 
10-lb.  Bells. 

One 

1.5-lb.  Bell. 

R.— L. 

Two 
1.5-lb.  Bells. 

Two 
20-lb.  Bells. 

Standing. 

Lying  Down. 

April    6. 
"      9. 

3  lbs. 

1 

(( 

io6 

10— 10 

5 

Instructed. ' 

Instructed. 

"    11. 

(( 

150 

2  15-lb. 

beUs. 

25—25 

1  20-lb. 

bell. 

15 

10 

2 

5 

"     13. 

(( 

50 

25—25 

25 

12 

5 

10 

"     16. 

ti 

54 

30—30 

35 

18 

7 

12 

"    18. 

11 

60 

35—35 

1  25-lb. 

bell. 

40 

2  20-lb. 

bells. 

20 

7 

15 

"     20. 

a 

70 

20—20 

20 

30 

10 

15 

"     25. 

a 

90 

22—22 

25 

33 

15 

16 

"     27. 

11 

100 

35—35 

30 

50 

17 

20 

"    30. 

(I 

110 

50—50 

35 

60 

20 

22 

May      2. 

(I 

120 

60—60 
1  30-lb. 

36 

70 
2  25-lb. 

20 

25 

bell. 

bells. 

64-lb.  bar. 

64-lb.  bar. 

"       4. 

u 

140 

20—20 

40 

25 

5 

10 

7." 

ii 

150 

25—25 

45 

30 

7 

12 

'^      14. 

It 

160 

27—27 

50 

34 

9 

13 

"     16. 

11 

170 

30—30 

55 

40 

10 

14 

This  method  combines  the  forcible  correction  of  deformity  by  means 
of  the  "  heavy  work  "  with  muscle  building.  It  has  the  merit  also  of 
making  an  immediate  mental  impression  upon  the  patient  which  no 
other  system  can  make ;  for  if  the  patient  does  not  "  strain  every 
nerve,"  he  must  certainly  exercise  every  muscle,  to  preserve  the 
equilibrium  while  supporting  the  heavy  weights,  and  tliis  mental  im- 
pression is  undoubtedly  one  of  the  important  elements  in  successful 
treatment. 

The  system  has  the  disadvantage,  if  disadvantage  it  may  be  called, 
of  making  class  work  impos.sible,  for  the  patient  must  be  under  con- 
stant supervision,  not  only  that  he  may  be  urged  to  the  limit  of  his 
capacity,  but  that  over-strain  may  be  avoided  as  well. 


164  LATERAL   CURVATURE  OF  THE  SPIXE. 

It  might  appear  from  the  description  that  the  clanger  of  over-work 
is  great,  but  in  a  long  series  of  cases,  some  of  which  were  compli- 
cated by  defects  of  the  heart  and  lungs,  no  unfavorable  symptoms  have 
been  observed  by  Teschner.  The  system  is,  however,  one  that  can 
only  be  practiced  by  a  physician. 

Another  system  of  exercises  is  that  followed  at  the  Hospital  for 
Ruptured  and  Crippled.  Dr.  Truslow  has  been  kind  enough  to  out- 
line for  me  some  of  the  more  important  exercises  and  to  illustrate  them 
with  the  photographs  that  are  reproduced  here. 

The  objects  of  the  treatment  are :  (1)  To  overcome  the  patient's 
faulty  habits  of  posture  by  the  repeated  purposeful  assumption  of 
proper  postures ;  in  other  words,  to  counteract  the  deformity  habit 
by  training  the  mental  and  muscular  perception  of  symmetry.  (2) 
To  stimulate  and  to  strengthen  the  weakened  muscles,  particularly 
those  muscular  groups  that  are  especially  concerned  in  overcoming  the 
deformities,  and  which,  for  the  present  purpose,  may  be  considered  as 
weak. 

For  convenience  of  description  the  exercises  are  divided  into  two 
classes  :     (1)  Self  correction  ;  (2)  Muscle  building. 

Self  Correctiox,  Postures. — The  first  exercises  (a  and  6)  in  self 
correction  are  for  the  purpose  of  overcoming  the  antero-posterior  de- 
formities that  usually  accompany  lateral  deviation  of  the  spine. 

(a)  Head  Bending  Bachward. — In  this  exercise  the  chin  is  not  tilted 
upward,  but,  the  head  being  held  level,  the  neck  is  drawn  directly 
backward  until  the  cervical  and  upper  part  of  the  dorsal  segments  of 
the  spine  are  completely  extended.  Thus  by  increasing  the  distance 
between  the  points  of  attachment  of  the  sterno-mastoids  and  the 
scaleni,  strong  traction  is  made  upon  these  muscles  with  the  effect  of 
elevating  the  upper  part  of  the  thorax,  an  important  feature  in  the 
exercise. 

(6)  Trunk  Bending  Forward  and  Trunk  Raising. — The  patient  stands 
in  the  erect  posture  with  the  spine  extended  and  the  chest  expanded 
as  in  the  previous  exercise.  The  trunk  is  then  bent  forward  (similar 
to  Fig.  127),  the  only  motion  being  at  the  hip  joints.  The  trunk  is 
then  raised  again  to  the  former  position,  care  being  taken  to  keep  the 
hips  farther  back  than  the  chest.  In  both  flexion  and  extension  the 
spine  must  be  rigidly  held  in  the  corrected  attitude  and  there  must 
be  no  motion  at  the  knees.  There  is,  of  course,  a  movement  corre- 
sponding to  extension  at  the  ankle  joints  when  the  legs  and  buttocks 
are  thrown  backwards  to  compensate  for  the  forward  bending  of  the 
body.  The  object  of  this  exercise  is  to  train  the  patient  to  keep  the 
hips  back  and  the  chest  forward. 

The  other  exercises  in  self  correction  are  for  the  purpose  of  over- 
coming lateral  deviation  of  the  spine,  the  right  dorsal,  left  lumbar 
curve,  with  the  high  right  shoulder  and  the  prominent  left  hip,  being 
taken  as  a  type.     (Fig.  122.) 

This  series  is  arranged  in  a  progression,  and  each  one  must  be 
learned  before  the  next  in  order  is  attempted. 


EXERCISES. 


165 


(c)   Left  Neck  Firm. — The  left  hand  is  placed  behind  the  neck,  the 
left  shoulder  is  raised  and  the  left  elbow  is  held  well  back.     This  pos- 


FiG.  122. 


Typical  lateral  curvature.     Kight  dorsal.     Left  lumbar. 

tare  impresses  upon  the  patient  the  necessity  ot  approximating  the 
left  shoulder  and  the  neck.     (Fig.  123.) 


166 


LATERAL   CURVATURE  OF  THE  SPINE. 


(d)  Body  Inclination  to  the  Left. — Tliis  is  a  most  important  posture  ; 
it  is  intended  to  correct  mechanically  the  faulty  inclination  to  the  right 
and  to  overcome  the  upper  curve  by  traction  on  its  concavity.  The 
patient  holding  the  arm  in  the  first  position  is  instructed  to  stretch 
well  out  with  the  left  elbow,  rotating  upward  and  abducting  the  left 


Fig.  123. 


Left  neck  firm. 


scapula  as  much  as  possible.  This  puts  upon  the  stretch  the  rhom- 
boidei  and  the  lower  half  of  the  trapezius  of  the  left  side,  thus  mak- 
ing strong  traction  upon  their  points  of  attachment  in  the  dorsal  con- 
cavity. At  the  same  time  the  patient  is  directed  to  sway  the  pelvis 
to  the   right.     This  usually   requires  assistance  at  first,  for  it  brings 


EXERCISES. 


167 


into  action  certain  deep  back  muscles,  over  which  one  has  ordinarily 
but  little  control.  The  shoulders  must  be  kept  level  and  the  proper 
relation  of  the  head  and  neck  to  the  left  shoulder  must  not  be  dis- 
turbed in  this  forced  stretch  to  the  left.     (Fig.  124.) 

(e)    Chest  Pressing  ivith  the  Right  Hand. — The  patient  holding  the 
left  arm  in  the  first  position  presses  the  right  hand  firmly  against  the 

Fig.  124. 


Body  inclination  to  the  left. 


dorsal  convexity.  This  posture  may  be  employed  to  advantage  if 
there  is  a  long  right  dorsal  curve,  when  it  is  an  efficient  aid  to  the 
left-sided  pull  of  the  two  former  exercises. 

(/)  Right  Neck  Finn. — The  right  hand  is  placed  behind  the  neck, 
without,  however,  disturbing  the  improved  position  induced  by  the 
first  exercises.     With  both  hands  placed  behind  the  head,  the  arms 


168 


LATERAL   CURVATURE  OF  THE  SPINE. 


being  in  a  symmetrical  position,  there  is  better  mechanical  fixation  of 
the  head,  neck  and  upper  part  of  the  trunk  during  the  next  exercise. 
(Fig.  125.) 

{g)  Left  Hip  Twisting  Backward. — In  posture  (c?)  the  pelvis  was 
swayed  slightly  to  the  right ;  it  is  now  twisted  slightly  backward  on 
the  left  side  to  overcome  the  twist  in  the  lumbar  spine  which  usually 
throws  this  side  of  the  pelvis   somewhat   forward.      This   correcting 

Frfi.  125. 


Right  neck  Arm. 


motion  should  be  carried  out  in  the  lower  dorsal  and  lumbar  seg- 
ments and  it  should  not  affect  the  attitude  of  the  remainder  of  the 
trunk. 

(A)  Left  Oblique  Stride  Standing. — The  pelvic  twist  and  right-sided 
sway  being  rigidly  maintained,  the  left  foot  is  placed  about  two  foot- 
lengths  forward  and  a  little  outward.  Upon  this  leg  the  greater  part 
of  the  weight  of  the  body  is  now  supported.  This  allows  a  slight 
downward  tilt  of  the  pelvis  to  the  right,  and  lessens  the  left  lumbar 
convexity.     (Fig.  126.)     The  positions,  attained  by  the  progressive 


EXERCISES. 


169 


•exercises  to  this  point,  being  maintained,  the  patient  continues  with 
(i)   Trunk  Bending  Forivard. — In  this  posture,  motion  takes  place 


Fig.  126. 


Left  oblique  stride  stauUiuf. 


in  the  hip  joints  only,  as  in  the  first  exercise.     This  exercise  further 
emphasizes  the  symmetrical  position  of  the  head  and  neck,  the  left- 


170 


LATERAL   CURVATURE  OF  lEE  SPINE. 


sided  inclination  of  the  upper  half  of  the  trunk,  the  right-sided  incli- 
nation of  the  lower  half,  the  twist  and  downward  tilt  of  the  pelvis. 
(Fig.  127.)  The  return  to  the  improved  standing  position  should  be 
made  in  this  order:  (1)  Trunk  raising;  (2)  Replacement  of  the  left  foot^ 
(3)  Return  of  both  arms  to  the  sides.  This  is  done  slowly  and  care- 
fully by  the  patient,  who  attempts  to  maintain  the  improved  posture. 

Fig.  127. 


Tniuk  beudiug  forward. 


The  postures  constitute  a  progression  which  cannot  be  learned  in  less 
than  seven  treatments ;  often  much  more  time  is  required.  As  each 
part  is  learned,  it  should  be  practiced  at  home  until  the  next  treatment, 
when  a  new  posture  is  added,  if  it  appears  that  progress  can  be  made. 


EXERCISES.  171 

These  successive  postures  are  in  reality  exercises  in  that  it  requires 
constant  muscular  effort  to  retain  them,  but  they  are  not  exercises  in 
the  sense  of  repeated  alternations  of  position.  The  series  is  simply  an 
elaboration  of  what  is  called  the  keynote  posture.  The  raising  of  the 
left  elbow,  for  example,  makes  it  easier  for  the  patient  to  overcome  the 
distortion  of  the  upper  part  of  the  spine ;  it  also  instructs  him  in  the 
manner  of  holding  the  spine  in  the  improved  position  after  the  arm  is 
placed  by  the  side.  The  same  is  true  of  all  the  postures ;  each  one 
suggests  and  makes  correction  easier,  and  after  sufficient  practice  the 
patient  should  be  able  to  assume  the  corrected  position  without  plac- 
ing the  arm  or  the  leg  in  the  preliminary  attitude.  Thus  the  suc- 
cessive postures  are,  as  it  were,  letters,  which,  placed  together  one  by 
one,  make  a  complete  word,  or  the  best  possible  position  that  the 
j)atient  can  assume.  At  first  the  patient  must  use  the  letters  and 
slowly  spell  out  the  corrected  attitude,  but  after  the  muscles  have  been 
educated  by  the  repeated  assumption  of  each  posture,  and  when  the 
perception  of  symmetry  has  been  acquired,  the  corrected  attitude  may 
be  assumed  at  will,  and,  in  part,  at  least,  instinctively  retained  at  all 
times. 

Muscle  Building,  Exeecises. — In  the  treatment  of  lateral  curva- 
ture one  aims  to  strengthen  : 

1.  The  posterior  cervical  muscles. 

2.  The  dorsal  and  lumbar  muscles. 

3.  The  muscles  of  vertebro-scapula  attachment. 

4.  The  abdominal  muscles. 

5.  The  thigh  and  leg  muscles. 

6.  The  chest-expanding  muscles. 

The  following  exercises  have  been  selected  as  best  adapted  for  this 
purpose.  Each  one  should  be  performed  five  or  more  times  according 
to  the  strength  of  the  patient. 

(a)  Opposite  Standing,  Head  Bending  Backward,  Resisted. — The 
patient  stands  before  a  wall  or  a  shoulder-high  horizontal  bar  on  which 
the  hands  are  placed  with  the  arms  extended.  The  head  is  bent  for- 
ward and  is  then  forced  backward,  the  latter  movement  being  resisted 
by  the  hand  of  the  surgeon.  This  exercise  is  designed  to  strengthen 
the  posterior  cervical  muscles. 

(b)  Opposite  Bend  Standing,  Trunk  Jlaising,  Resisted. — The  patient 
stands  with  the  upper  part  of  the  thighs  in  contact  with  a  table  or 
horizontal  bar.  The  hands  are  placed  behind  the  neck  and  the  body 
is  bent  forward  on  the  hip  joints  as  in  the  first  exercise.  The  surgeon 
standing  behind  places  his  right  hand  over  the  posterior  dorsal  prom- 
inence and  his  left  over  the  lumbar  projection.  The  patient  then 
raises  the  trunk  to  the  erect  position  against  the  combined  resistance. 
(Fig.  128.)  With  a  little  practice  the  surgeon  learns  to  give  an  out- 
ward twisting  motion  to  his  hands  while  resisting,  which  tends  to  un- 
twist the  spinal  rotations.  When  the  dorsal  rotation  to  the  right  is 
marked  this  untwisting  may  be  facilitated  by  encircling  the  patient's 
chest  with  the  left  hand  while  with  the  right,  strong  forward  and  out- 


172 


LATERAL   CURVATURE   Ot    THE  SPINE. 


ward  pressure  is  made  as  the  patient  raises  the  body.     This  exercise  is 

for  the  purpose  of  developing  the  muscles  of  the  erector  spinse  group. 

(c)  Prone  Lying,  Head  and  Shoulder  Raising   "  The  SeaU' — The 


Fig.  128. 


"  Opposite  bend  standing."     Trunk  raising  resisted. 

patient  lies  upon  a  table  or  upon  the  floor,  and  raises  the  head  and 
chest — "  looks  at  the  ceiling."  Progression  is  made  in  the  increased 
leverage  of  arm-weight  transference. 

1 .  With  the  hands  on  the  backs  of  the  thighs. 


EXERCISES. 


173 


174  LATERAL   CURVATURE  OF  THE  SPINE. 

2.  With  the  left  hand  behind  the  neck  and  the  right  hand  on  the 
back  of  the  thigh. 

3.  With  both  hands  behind  the  neck,  and  with  the  elbows  well  out 
and  back. 

4.  "  Swimming."  The  arm  motions  of  swimming,  in  three  counts. 
This  exercise  is  to  strengthen  the  muscles  of  the  back  from  the  head 
to  the  pelvis. 

(d)  Prone  Lying,  "  Diving." — The  patient  lies  upon  a  table,  the 
trunk  and  pelvis  projecting  beyond  its  edge,  the  limbs  being  fixed  by 
a  strap  or  by  the  weight  of  another  person.  The  body  is  then  bent 
downward  and  is  raised  again  to  the  horizontal  position.  (Fig.  129.) 
In  this  exercise,  assistance  will  be  required  at  first.  Progression  is 
made  by  transference  of  arm  weights,  as  in  the  former  exercise,  thus : 

1.  With  the  hands  on  the  hips. 

2.  With  the  arms  stretched  out  at  right  angles  to  the  body. 

3.  With  the  hands  behind  the  neck. 

4.  With  the  arms  extended  in  the  line  of  the  body. 

This  exercise  is  for  the  purpose  of  strengthening  all  the  muscles  of 
the  back. 

(e)  Prone  Lying,  Leg  Raising. — The  patient,  lying  in  the  prone  pos- 
ture upon  the  floor  or  table,  lifts  the  limbs  (over-extends)  alternately, 
the  raised  leg  being  held  perfectly  straight.  When  the  left  thigh  is 
extended,  as  much  as  the  ilio-femoral  ligament  will  allow,  the  left  side 
of  the  pelvis  is  tilted  upward  also,  thus  untwisting  the  lumbar  spine. 
Progression  in  this  exercise  is  made  as  follows  : 

1.  Alternate  leg  raising,  unresisted. 

2.  Alternate  leg  raising,  resisted. 

3.  The  leg  motions  of  swimming,  in  three  counts. 

In  this  exercise  the  entire  lower  extremities  must  project  beyond  the 
supporting  table.  The  exercises  are  for  the  purpose  of  strengthening 
the  lumbar  muscles  and  the  extensors  of  the  thigh. 

(/)  Opposite  Sitting,  Baekward  Bending  of  the  Trunk. — The  patient 
is  seated  upon  a  bench,  and  the  feet  are  fastened  to  the  floor.  The 
trunk  being  held  in  a  position  of  complete  extension  is  bent  slowly 
backward,  motion  being  at  the  hip  joint  only.     Progression. 

1.  With  the  hands  behind  the  hips. 

2.  With  the  left  hand  behind  the  neck,  the  right  hand  on  the  hip. 

3.  With  both  hands  behind  the  neck. 

4.  With  both  arms  extended  upward. 

At  first  the  body  is  bent  backwards  about  forty-five  degrees,  later 
until  the  head  touches  the  floor.  This  exercise  is  to  strengthen  the 
abdominal  muscles. 

{g)  The  Horizontal  Bar.  "  Pidl-ups." — The  patient  hangs  by  the 
hands  and  is  assisted  to  "  chin  the  bar."  The  body  is  then  allowed  to 
sink  slowly  back  into  the  former  position,  the  elbows  are  held  well 
back,  and  the  patient  is  instructed  to  bear  as  much  of  the  weight  as  is 
possible  with  the  left  arm  and  shoulder.  This  exercise  corrects  the 
dorsal  curve  by  means  of  muscular  activity,  and  the  lumbar  curve  by 


THE  REMOVAL   OF  SUPEBINOUMBENT  WEIGHT.  175 

the  weight  of  the  suspended  pelvis  and  limbs.  The  muscles  used  are 
those  with  vertebro-scapula  attachment. 

(/i)  Left  Leg  Standing,  Pelvis  Tilting. — The  patient  stands  upon  the 
edge  of  a  bench,  supporting  the  weight  on  the  left  leg,  the  right  leg 
being  suspended  beyond  the  side  of  the  bench.  While  the  head  and 
trunk  are  kept  in  the  corrected  position,  the  pelvis  is  made  to  tilt 
sharply  downward  on  the  right,  by  lowering  the  right  leg,  while  the 
left  is  kept  perfectly  stiff.  This  has  the  effect  of  straightening  the 
lumbar  curve. 

(i)  Left  Leg  "  Hopping." — Both  hands  are  placed  behind  the  neck 
and  the  weight  is  supported  entirely  upon  the  ball  of  the  left  foot.  In 
this  attitude  the  patient  hops  ten  or  more  times.  This  exercise,  like 
the  last,  tends  to  straighten  the  spine  and  to  strengthen  the  muscles  of 
the  left  leg,  which  are  often  somewhat  weakened  from  disuse. 

(J)  Respiratory,  Half  Reclining,  Arm  Extensions  and  Flexions,  Re- 
sisted.— The  patient  sits  in  a  chair  with  an  inclined  back,  or  lies  upon 
a  low  table  with  hard  pillows  under  the  mid-dorsal  region,  so  that  the 
upper  dorsal  and  cervical  segments  of  the  spine  must  be  over-extended. 
The  arms  are  stretched  upward  and  backward,  and  the  hands  are 
grasped  by  the  surgeon,  who  stands  behind  and  resists  the  patient's 
downward  pull.  With  the  upward  stretch  of  the  arms  and  pull  by  the 
surgeon,  the  patient  inhales  forcibly.  With  the  downward  pull  against 
resistance,  the  patient  exhales  forcibly.  This  exercise  is  made  in  the 
rhythm  of  slow  breathing. 

When  the  patient  has  been  thoroughly  instructed  in  self  correction 
and  in  the  exercises  for  muscle  building,  general  gymnastics  for  sys- 
tematic motor  training,  may  be  given  effectively  in  groups  of  fifteen  or 
twenty  pupils.  For  such  exercises  the  "  days  order  "  of  the  Swedish 
Educational  Gymnastics  is  preferred. 

These  two  systems  of  treatment  by  gymnastics  have  been  selected  as 
the  most  practicable  of  the  many  that  have  been  devised.  It  may  be 
stated  that  any  treatment  that  makes  the  spine  more  flexible,  that 
overcomes  faulty  attitudes  and  that  strengthens  the  muscles,  must  be 
of  benefit  to  the  patient,  the  degree  of  benefit  corresponding  to  the  per- 
sistence and  energy  of  the  pupil  and  the  instructor,  rather  than  to  any 
particular  theory  on  which  such  treatment  is  based. 

The  Removal  of  Superincumbent  Weight.^The  removal  of 
superincumbent  weight  by  the  assumption  of  the  reclining  posture 
whenever  the  patient  is  fatigued,  is  an  important  adjunct  in  the  treat- 
ment of  a  certain  class  of  cases. 

Self  Suspension. — Self  suspension,  by  means  of  the  halter  and 
pulley  is  of  service  in  overcoming  secondary  contractions  of  the  tissues, 
and  thus  it  aids  in  the  correction  of  deformity.  It  is  often  efficacious  also 
in  relieving  the  discomfort  that  is  sometimes  a  troublesome  symptom 
when  the  distortion  is  extreme.  While  the  patient  is  suspended,  forcible 
manual  correction  of  the  deformity  can  be  applied  to  advantage. 

Suspension  from  the  horizontal  bar  acts  in  a  similar  manner,  although 
it  is  less  effective  than  when  the  traction  is  made  upon  the  entire  spine. 


176 


LATERAL   CURVATURE  OF  THE  SPINE. 


In  this  form  of  suspension,  the  bar  should  be  oblique  in  direction,  the 
high  side  for  the  low  shoulder.  Thus  a  passive  "  keynote  "  is  in- 
duced while  the  patient  is  suspended.  Exercises  in  this  position,  for 
example,  flexion  and  extension  of  the  thighs,  swaying  the  trunk  from 
side  to  side,  "  chinning  "  the  bar  and  the  like,  are  useful. 

The  Use  of  Braces  or  Other  Supports. — In  the  treatment  of  the 
ordinary  type  of  lateral  curvature, 

when   there   is   an   opportunity   for  Fig.  131. 

proper  gymnastic  training,  support 
is  not  indicated.  There  are,  how- 
ever, exceptional  cases  in  which  the 
deformity  habit  is  so  persistent,  and 


Fig.  130. 


Self  suspension  illustrating  the  effect  of  traction  in  lessening  deformity.     (Gibney.) 


in  which  the  voluntary  efforts  of  the  patient  to  assume  a  better 
attitude  are  so  ineffective,  that  support  may  be  employed  for  a  time 
with  advantage. 

The  best  support  is  a  plaster  corset  applied  while  the  patient  is  sus- 


FORCIBLE  CORRECTION  OF  DEFORMITY. 


177 


pended.  This  may  be  removed  at  night  and  when  the  exercises  are 
performed.  Even  while  the  corset  is  worn,  the  patient  should  endeavor 
to  improve  upon  the  attitude  which  it  enforces,  by  assuming  the  key- 
note position  and  by  flexing  and  extending  the  trunk  on  the  hips. 

When  the  deformity  is  dependent  upon  irremediable  injury  or  dis- 
ease, for  example,  anterior  poliomyelitis  or  empyema,  some  form  of 
brace  may  be  employed  to  prevent  excessive  lateral  deviation  of  the 
trunk  ;  and  in  cases  of  fixed  deformity  in  older  subjects,  especially  if 
the  patient  is  obliged  to  follow  a  fatiguing  occupation,  a  support  may 
be  indicated,  because  of  symptoms  of  discomfort  or  pain. 

Support  is  employed  primarily  with  the  aim  of  preventing  an  increase 
of  deformity  and  to  relieve  symptoms  incidental  to  the  deformity.  It 
may,  in  some  degree,  also  serve  as  a  corrective  appliance.  If  it  holds 
the  spine  in  the  extended  position  or  induces  lordosis,  it  may,  by  reliev- 

FiG.  132. 


The  Knight  spinal  brace. 


ing  the  bodies  of  the  vertebrae  in  part  from  the  deforming  influence  of 
superincumbent  weight,  allow  for  slight  untwisting  of  the  rotation  and 
a  corresponding  transformation  of  the  distorted  parts.  On  this  princi- 
ple a  light  steel  brace  after  the  Taylor  model  may  be  as  effective  as 
any  of  the  more  complicated  appliances,  as  was  suggested  many  years 
ago  by  Judson.  Corsets  of  other  material  than  plaster,  for  example, 
of  paper,  or  of  aluminium,  as  suggested  by  Phelps,  may  be  employed 
when  the  deformity  is  fixed  and  when  no  change  in  the  position  or 
size  of  the  trunk  is  to  be  expected.  The  Knight  brace,  when  care- 
fully adjusted,  appears  to  meet  the  requirements  fairly  well,  and  when 
less  support  is  needed,  an  ordinary  corset  strengthened  by  light  steels 
may  be  sufficient. 

Forcible  Correction  of  Deformity. — In  the  treatment  by  gymnastic 
12 


178 


LATERAL   CURVATURE  OF  THE  SPINE. 


Fig.  133. 


exercises  the  patients  are  supposed  to  overcome  by  voluntary  effort,  as 
far  as  is  possible,  the  secondary  accommodative  contractions  of  the  soft 
parts  that  prevent  the  correction  of  the  deformity.  But  in  many  in- 
stances the  voluntary  correction  of  deformity  may  be  supplemented 
with  advantage  by  the  employment  of  force.  For  example,  the  patient 
may  use  the  weight  of  the  body  as  a  means  of  correction  by  forcibly 
flexing  the  trunk  over  a  padded  bar  (Fig.  138)  and  a  variety  of  similar 

postures,  either  active  or  passive, 
with  or  without  suspension  may 
be  utilized  with  the  same  object. 
Corrective  force  applied  by  the 
hands,  the  patient's  trunk  being 
flexed  and  rotated  in  the  directions 
opposed  to  the  deformities,  al- 
though the  most  effective  method, 
is  the  most  fatiguing,  and  ma- 
chines have  been  constructed  with 
the  aim  of  applying  the  force  in 
similar  manner.  This  is  illustrated 
by  the  appliance  of  Hoffa,  which 
has  been  modified  by  Schede  and 
others.  In  this  machine  the  pa- 
tient is  suspended,  the  hips  are 
fixed  and  the  pressure  screws  are 
applied  upon  the  convexities  of  the 
double  curve,  with  the  aim  of  un- 
twisting the  spine.  The  correction 
is  maintained  for  fifteen  minutes  or 
longer,  and  it  is  then  followed  by 
the  regular  exercises  of  the  day. 
(Fig.  133.) 

The  Forcible  Correction  of  Defor- 
mity Combined  with  Fixation. — 
Forcible  correction  and  fixation  is 
the  treatment  of  selection  for  resis- 
tant lateral  curvature  in  early 
childhood,  because  one  cannot  com- 
mand the  co5peration  of  the  patient 
in  maintaining  the  proper  attitude, 
and  because  the  rapid  growth  at 
this  age,  which  favors  the  increase  of  the  deformity  is  equally  favorable 
to  its  cure  if  the  static  conditions  can  be  changed. 

For  example,  one  treats  the  severe  rhachitic  kyphosis  of  infancy  by 
fixation  in  the  horizontal  position,  and  by  daily  manual  correction  of 
the  deformity.  And  in  the  treatment  of  older  children,  in  whom  pos- 
terior or  lateral  deformity  is  fixed,  one  is  justified  in  using  the  same 
method  for  its  relief  and  cure  that  would  be  employed  in  the  treatment 
of  Pott's  disease.     In  this  class  the  plaster  of  Paris  jacket,  applied 


Forcible  correction  by  means  of  the  modified 
Hoflfa  appliance.     (Bradford  and  Brackett.  ) 


FORCIBLE  COBEECTION  OF  DEFORMITY.  179 

while  the  trunk  is  held  in  the  best  possible  position,  is  the  treatment  of  se- 
lection, a;  treatment  that  should  be  continued  until  the  deformity  is  cured 
or  until  further  rectification  by  this  means  is  found  to  be  impossible. 

The  most  convenient  method  of  applying  the  jacket  is  by  means  of 
the  ordinary  suspension  apparatus.  The  back  having  been  carefully 
padded  at  the  points  of  pressure,  the  patient  is  suspended  and  while 
traction  and  manual  corrective  force  are  exerted  the  plaster  bandages 
are  applied.  In  this  correction  two  points  are  of  especial  importance, 
to  attain  as  much  extension  or  over-correction  as  possible  and  to  sway 
the  entire  body  in  the  direction  opposite  to  the  habitual  inclination. 
By  over-extension  one  removes  the  weight  in  part  from  the  vertebral 
bodies  that  are  primarily  deformed,  and  by  lateral  correction  one 
endeavors  to  change  the  relation  of  the  weight  to  the  distorted  part. 
This  improved  position  must  be  carefully  maintained  by  the  hands 

Fig.  134. 


Congenital  scoliosis.    After  treatment  for  three  years  by  forcible  correction  and  fixation  by  plaster 
jackets.    Showing  the  disappearance  of  the  rotation. 

until  the  plaster  bandages  have  become  firm.  The  jackets  may  be 
changed  at  intervals  of  a  month  or  more  and  at  each  application  one 
attempts  to  improve  upon  the  former  position. 

The  jacket  is  used  in  preference  to  the  corset  because  it  holds  the  spine 
more  perfectly.  It  is  of  course  a  disadvantage  to  employ  such  restraint, 
but  as  has  been  stated  the  prognosis  in  fixed  rotary  lateral  curvature  in 
a  young  child  is,  as  regards  ultimate  deformity,  extremely  unfavorable, 
and  one  is  justified  therefore  in  sacrificing  muscular  activity  in  order  that 
the  original  deformity  of  the  bones  may  be  remedied.  As  an  illustra- 
tion of  persistence  in  this  method  of  treatment  it  may  be  stated  that  it 
was  continued  by  me  for  nearly  three  years  in  one  case  of  extreme 
scoliosis  of  congenital  origin  with  most  gratifying  success.    (Fig.  134.) 

The  jackets  may  be  applied  also  in  the  horizontal  position,  traction 
being  exerted  upon  the  arms  and  legs,  combined  with  manual  pressure 


180  LATERAL   CURVATURE  OF  THE  SPINE. 

on  the  trunk,  somewhat  after  the  manner  of  the  Calot  method  of  cor- 
rection of  the  deformity  of  Pott's  disease. 

When  the  deformity  has  been  overcome,  or  when  the  continuation 
of  the  treatment  seems  undesirable,  the  jacket  may  be  replaced  by  a 
corset,  which  may  be  removed  for  daily  massage  and  for  exercises.  This 
may  be  finally  discarded  when  the  muscular  strength  has  been  regained. 

As  has  been  stated,  forcible  correction  and  fixation  is  essentially  a 
treatment  of  deformity  in  early  childhood.  But  in  certain  instances, 
when,  for  example,  the  deformity  is  extreme  or  is  increasing  rapidly, 
it  may  be  employed  in  adolescence.  In  the  treatment  of  this  class  of 
cases  the  plaster  jacket  is  usually  applied  while  the  patient  is  fixed  in 
the  best  possible  position  by  means  of  some  form  of  pressure  apparatus, 
as  is  illustrated  in  Fig.  133. 

Forcible  correction  of  deformity  under  ansesthesia  has  little  to  recom- 
mend it,  since  whatever  deformity  can  be  corrected  with  anaesthesia 
can  be  corrected  without  it. 

The  Volkmaxx  Seat. — In  cases  of  primary  lumbar  curvature,  or 
when  the  secondary  curve  of  this  region  is  pronounced,  the  attitude 
may  be  improved  and  the  deformity  may  be  corrected  in  part  by  seat- 
ing the  patient  on  an  inclined  plane,  the  high  side  beneath  the  low  hip, 
thus  lessening  the  convexity  of  the  curve. 

The  High  Shoe. — The  same  object  may  be  attained  in  the  erect 
posture  by  the  use  of  a  higher  heel,  or  heel  and  sole.  The  elevation 
may  be  from  a  half  inch  to  an  inch  and  a-quarter,  the  amount  being 
regulated  by  its  effect  upon  the  contour  of  the  trunk. 

Posture  axd  Suppoet  During  Recumbexcy. — The  attitudes 
habitually  assumed  during  recumbency  should  be  investigated.  The 
bed  should  be  provided  with  a  hard  mattress  and  a  low  pillow,  and 
the  patient  should  be  encouraged  to  lie  upon  the  side  in  an  attitude 
which  opposes  the  deformity,  or  upon  the  back.  The  rectification  in- 
duced by  such  an  attitude  may  be  still  further  increased  by  the  use  of 
a  hard  pillow  beneath  the  convexity  or  beneath  the  back,  and  in  cer- 
tain instances  the  Barwell  sling  may  be  employed  wdth  advantage. 

Gexeeal  Treatment. — The  importance  of  improving  the  general 
condition  of  the  patient  by  regulation  of  the  diet,  by  cold  baths  and 
by  active  exercise  in  the  open  air  is  self-evident.  The  strain  upon  the 
back  should  be  lessened  by  providing  proper  seats  and  by  limiting  the 
time  passed  in  passive  attitudes,  and  by  lessening,  as  far  as  is  possible, 
the  restraint  of  the  clothing.  These  precautions  are  of  almost  equal 
importance  with  the  active  treatment. 

The  Duration  of  Treatment. — The  duration  of  treatment  depends  of 
course  upon  the  character  of  the  deformity  and  upon  its  causes.  In 
the  ordinary  type  of  adolescent  scoliosis,  the  duration  of  active  treatment 
is  usually  from  three  to  six  months.  In  this  time  the  muscles  may  be 
so  strengthened  and  the  necessity  for  constant  attention  to  the  attitudes 
may  be  so  impressed  upon  the  patient,  that  the  simple  exercises  which 
may  be  performed  at  home,  may  be  sufficient.  It  is  well,  however,  if  pos- 
sible, to  keep  the  patient  under  supervision  during  the  period  of  growth. 


CHAPTER    IV. 

DEFORMITIES   OF    THE    S'Pl^Il.— Continued.      DEFORMI- 
TIES  OF  THE  CHEST.     THE  FUXCTIOXAL 
PATHOGEXESIS   OF   DEFORMITY. 

Variations  in  the  Contour  of  the  Spine. 

OxE  recognizes  a  certain  contour  of  the  spine  as  normal,  but  there 
are  variations  from  this  type  which,  within  certain  hmits,  can  hardly 
be  classed  as  abnormal.     Two  of  these  have  been  mentioned,  the  round 


Fig.  135. 


Fig.  1.36. 


The  hollow  round  back.     (Hoffa.) 


r/; 


The  round  back.     (Hoffa.) 


back    (Fig.   136)  in  which   there  is    a   general    forward  droop  most 
marked  at  the  shoulders  ;    and  the  hollow  round  back  (Fig.  135)  in 


182 


DEFORMITIES  OF  THE  SPINE. 


which  the  dorsal  kyphosis  and  the  lumbar  lordosis  are  somewhat  ex- 
aggerated. A  third  type  is  the  flat  back  (Fig.  71),  in  which  there  is 
neither  a  lumbar  lordosis  nor  a  dorsal  kyphosis.  In  the  marked  cases 
there  is  an  actual  prominence  in  the  lumbar  region,  while  the  scapulae 
project  backward  from  the  flattened  dorsal  spine.  This  type  of  back 
is  probably  the  result,  in  many  instances,  of  a  rhachitic  kyphosis 
which  was  most  prominent  in  the  lumbar  region.  The  flat  back  and 
the  round  back  predisposed  to  lateral  curvature. 


Antero-Posterior  Deformities  of  the  Spine. 

Kyphosis. — As  has  been  stated  in  the  chapter  on  Pott's  disease, 
the  spine  is  practically  straight  at  birth.  If  during  the  early  weeks  of 
life  an  infant  be  placed  in  the  sitting  posture  the  head  falls  forward  and 

the  spine  bends  into  a  long 
Fig.  137.  posterior  curve,  the  posture 

of  weakness.  The  normal 
anterior  convexity  of  the 
cervical  section  is  estab- 
lished when  the  gain  in  mus- 
cular power  enables  the  in- 
fant to  hold  the  head  erect, 
and  that  of  the  lumbar  re- 
gion when  the  pelvis  is  tilted 
downward  by  the  extension 
of  the  thighs  in  the  erect 
posture. 

In  the  erect  posture  the 
constant  tendency  of  the 
weight  of  the  head  and  of  the 
thoracic  and  abdominal  or- 
gans is  to  draw  the  spine  for- 
ward and  to  reestablish  the 
original  posterior  curve. 
This  tendency  is  resisted  by 
the  action  of  the  posterior 
muscles  of  the  trunk. 
AVhenever,  therefore,  the 
muscular  power  is  lessened 
or  the  body  is  over-burdened 
or  whenever  the  spine  is 
weakened  by  disease  the  ten- 
dency toward  the  original 
curve  of  weakness,  becomes 
apparent.  (Fig.  137.)  Thus  the  causes  of  an  abnormal  increase  in  the 
posterior  curvature  of  the  spine  are  very  numerous.  It  is,  as  has  been 
stated,  the  characteristic  attitude  of  weakness  as  is  illustrated  in  infancy 
and  in  old  age.    It  is  one  of  the  common  occupation  deformities  of  adult 


Marked  posterior  curvature  of  the  spine  apparently  in- 
duced by  weakness  incidental  to  illness. 


KYPHOSIS. 


183 


life ;  it  is  a  common  postural  deformity  of  childhood  and  adolescence. 
It  may  be  induced  by  a  variety  of  diseases  that  lessen  the  resistance  of 
the  spine  or  that  interfere  with  its  function.  For  example,  by  rhachitis, 
spondylitis  deformans,  osteitis  deformans,  Pott's  disease  and  affections 
of  a  similar  nature. 

The  kyphosis  of  rhachitis  is  most  marked  in  the  lower  region,  that 
of  spondylitis  deformans  may  involve  the  entire  spine,  while  the  simple 
postural  curvature  is  most  marked  in  the  upper  dorsal  region.  In  a 
number  of  the  postural  deformities  the  increase  in  the  dorsal  kyphosis 


Fig.  138. 


Fig.  139. 


Exercises  for  the  correction  of  posterior  curvatures  of  the  spine.     (Hoffa.) 

is  balanced  by  an  increased  lordosis  and  in  this  form  there  is  simply  an 
exaggeration  of  the  normal  curves  of  the  spine,  the  "hollow  round" 
back.  In  other  instances  there  is  a  general  forward  droop  of  the  trunk 
in  which  the  lumbar  lordosis  may  be  lessened  ;  this  form  is  more  com- 
mon in  childhood,  the  "  round  "  back. 

The  forms  of  kyphosis  that  are  the  direct  result  of  disease  have  been 
described  elsewhere.  Postural  kyphosis,  "  round  shoulders,"  is  one  of 
the  common  deformities,  and  in  childhood  its  etiology  is  similar  to  that 
of  lateral  curvature,  of  which  it  may  be  a  predisposing  cause.  Round 
shoulders  and  the  accompanying  flat  chest  may  be  induced  also  by  ob- 


184 


DEFORMITIES  OF  THE  SPINE. 


Fig.  140. 


structions  in  the  respiratory  passages,  such  as  enlarged  tonsils,  adenoids 
and  the  like  or  by  bronchitis  or  heart  disease.  Another  predisposing 
cause  is  clothing  that  prevents  the  full  expansion  of  the  chest  and  the 
extension  of  the  arras,  and  even  the  weight  of  clothing  suspended  from 
the  shoulders  may  be  a  factor  in  the  etiology.  These  possible  contribu- 
ting causes  should  be  investigated  in  all  cases  of  this  type. 

Treatment. — The  treatment  is  similar  to  that  of  lateral  curvature. 
The  assumption  of  the  military  attitude  with  the  head  erect,  the  chin 
depressed,  the  shoulders  thrown  back,  the  chest  expanded  and  the 
abdomen  retracted,  should  be  encouraged.     And  those  exercises  that 

expand  the  chest  and  that 
strengthen  the  muscles  of  the 
upper  part  of  the  spine,  are 
especially  important.  (Such 
exercises  are  illustrated  by 
Figs.  95,  96,  103,  104,  109, 
110,  119,  125,127,129,  138 
and  139.)  If  the  range  of 
vertical  extension  of  the  arms 
is  limited,  this  restriction  must 
be  overcome  before  the  defor- 
mity of  the  spine  can  be  per- 
manently improved.  In  well- 
marked  cases  the  patient 
should  be  encouraged  to  read 
or  study  in  the  prone  posture 
in  this  attitude  in  which  the 
trunk  must  be  supported  upon 
the  elbows  and  the  head  held 
backward,  there  is  necessarily 
an  involuntary  correction  of 
the  deformity.  In  certain 
instances,  a  light  spinal  brace 
may  be  employed  during  the 
hours  when  the  passive  atti- 
tude must  be  assumed,  but  as  a  rule  artificial  support  should  be  avoi- 
ded. (Fig.  140.)  Shoulder  braces,  so-called,  are  useless.  Clothing 
should  not  restrict  the  movements  of  the  arms  or  trunk,  and  as  little 
weight  as  possible  should  be  suspended  from  the  shoulders. 

Lordosis. — Lordosis,  or  an  abnormal  hollowness  of  the  back,  is  far 
less  common  than  kyphosis.  It  is  not  a  simple  postural  deformity, 
but  it  is  usually  secondary  to  disease  or  deformity  either  of  the  spine 
or  of  the  adjoining  members.  For  example,  lordosis  may  be  induced 
by  flexion  contraction  of  the  thighs  ;  it  is  a  symptom  of  congenital 
displacement  of  the  hips  ;  it  is  sometimes  a  result  of  certain  forms  of 
nervous  disease,  in  which,  because  of  muscular  weakness,  the  body  is 
swayed  backward  to  retain  the  balance,  as  in  pseudo-hypertrophic  pa- 
ralysis.    Lordosis  in  the  lumbar  region  may  be  a  compensation  for  a 


Tempered  steel  uprights  for  round  shoulders.     (Brad- 
ford AND  LOVETT.) 


ETIOLOGY. 


185 


Fig.  141. 


kyphosis  in  the  upper  segment.  It  is  caused  directly  by  spondylolis- 
thesis. -;It  may  be  a  congenital  deformity  and  it  is  said  to  be  a  pecu- 
liarity of  contortionists. 

Treatment. — As  lordosis  is  usually  a  secondary  deformity  its  treat- 
ment would  be  included  in  the  treatment  of  its  causes.  In  some  in- 
stances the  discomfort  which  is  usually  present  when  the  deformity  is 
well  marked  may  be  relieved  by  a  proper  corset  sufficiently  strong  to 
support  the  back. 

Congenital  Elevation  of  the  Scapula. 

Synonym. — Sprengel's  Deformity. 

Sprengel's  deformity  is  a  congenital  elevation  of  the  scapula  above 
the  level  of  its  fellow,  an  elevation  accompanied  in  most  instances  by 
rotation,  so  that  its  lower  angle  is  brought  nearer  to  the  spine.  The 
cervical  muscles  passing  to  the  scapula  are  shortened  and  changed  in 
direction.  Thus  its  mobility  is  lessened  and  consequently  the  range 
of  vertical  extension  of  the  arm  is  restricted. 
In  many  instances  the  deformity  is  accom- 
panied by  a  lateral  curvature  of  the  spine, 
the  convexity  being  usually  toward  the  de- 
formed side.  In  a  case  treated  at  the  Hos- 
pital for  Ruptured  and  Crippled,  the  eleva- 
tion of  the  scapula  was  accompanied  by 
marked  torticollis  and  asymmetry  of  the  face, 
and  in  two  cases  recently  reported  by  H.  A. 
Wilson  ^  the  posterior  border  of  the  scapula 
was  fixed  to  an  elongated  cervical  spinous 
process. 

The  first  adequate  account  of  the  deformity 
was  that  of  Sprengel,^  who  described  four 
cases  in  children  from  one  to  seven  years  of 
age.  In  1898  Pitsch^  described  seventeen 
other  cases  collected  from  literature,  and  since 
then  a  large  number  of  cases  have  been  re- 
ported by  other  observers.  In  four  cases, 
three  reported  by  Kolliker*  and  one  by 
Hoffa,  the  projecting  upper  border  of  the 
scapula,  reaching  nearly  to  the  clavicle,  was 
mistaken  for  an  exostosis. 

Etiology. — The  etiology  is  doubtful,  but 
the  deformity  appears  to  be  the  result  of  a 

constrained  position  of  the  foetus  in  utero.  In  two  of  Sprengel's  cases 
seen  soon  after  birth,  the  arm  appeared  to  have  been  fixed  behind  the 
back  of  the  child. 

Congenital  elevation  of  the  scapula  may  be  simulated  by  the  distor- 
tion and  muscular  atrophy  resulting  from  birth  palsy,  or  even  by  cer- 


Congenital  elevation  of  the  left 
scapula.    (Wilson.) 


'  Annals  of  Surgery,  April,  1900. 
2Archiv  fiir  klin.  Chir.,  Bd.  42,  1891. 


3Zeit.  fiir  Orth.  Chir.,  Bd.  6,  H.  1. 
"Centb.  fiir  Chir.,  1895. 


186  DEFORMITIES  OF  THE  CHEST. 

tain  cases  of  rotary  lateral  curvature  in  which  the  scapula  is  elevated 
and  prominent. 

Treatment. — If  the  case  is  seen  in  infancy  and  if  the  contraction  of 
the  vertebro-scapula  muscles  is  extreme,  the  shortened  tissues  may  be 
divided  by  open  incision  as  in  torticollis,  and  if,  as  in  Wilson's  cases, 
the  scapula  is  joined  to  the  spine  the  elongated  spinous  process  should 
be  removed.  In  older  subjects  no  treatment,  other  than  that  for  the 
lateral  curvature,  is  as  a  rule  indicated. 

The  Absence  of  Vertebrae. 

Absence  of  vertebrse  is  usually  associated  with  rhachischisis.  Three 
cases  however  have  come  under  my  observation  in  which  there  was 
absence  of  vertebrse  without  other  malformation.  In  two  of  the 
cases  the  deficiency  was  in  the  cervical  region,  in  one  in  the  lumbar. 
The  noticeable  shortness  of  the  affected  section  of  the  spine  was  the 
only  sjTnptom. 

Deformities  of  the  Chest. 

The  Flat  Chest. — The  so-called  flat  chest  is  an  accompaniment  of 
the  round  back.  (Fig.  136.)  In  most  instances  the  chest  is  not  ac- 
tually flattened  in  the  sense  that  its  antero-posterior  diameter  is  dimin- 
ished. It  appears  flatter  because  the  shoulders  and  scapulae  are  dis- 
placed forward. 

Woods  Hutchinson  has  called  attention  to  the  fact  that  the  so-called 
flat  chest  is  usually  a  round  chest,  in  the  sense  that  it  is  actually 
deeper  than  the  normal,  a  persistence  of  the  foetal  type.  He  suggests 
that  such  persistence  may  be  one  of  the  causes  of  so-called  round  shoul- 
ders, the  round  chest  affording  no  adequate  support  for  the  scapulae. 

Hutchinson  ^  has  presented  an  index  showing  the  relative  depth  of 
the  chest  at  different  ages,  illustrating  the  progress  from  the  keel  chest 
of  the  lower  orders  to  the  bellows  shape  of  the  adult  human  form. 
This  index  is  found  by  dividing  the  antero-posterior  diameter  at  the 
nipples  by  the  transverse  diameter  at  the  same  level,  hence  the  lower 
the  index,  the  longer  and  flatter,  more  bellows-like  the  chest. 

Foetal    index 103 

Infantile   "      87 

Child         "      90 

Adult        "      72 

Treatment. — The  treatment  of  the  so-called  flat  chest  is  similar  to 
that  of  the  round  shoulders  with  which  it  is  often  combined,  that  is 
by  exercises  conducted  with  the  special  object  of  improving  the 
strength  of  the  muscles  of  the  back  and  increasing  the  expansion  of 
the  upper  part  of  the  chest.  The  importance  of  correcting  the  de- 
formity, which  interferes  with  the  proper  expansion  of  the  lungs  and 
thus  predisposes  to  disease,  should  be  evident. 

Pigeon  Chest.     Synonym. — Pectus  Carinatum. 

'Journal  American  Medical  Association,  SejJt.  11,  1897. 


THE  FUNNEL   CHEST. 


187 


The  pigeon,  or  keel-shaped,  chest  resembles  the  quadrupedal  type 
in  that  "the  antero-posterior  is  increased  at  the  expense  of  the  lateral 
diameter.  The  sternum  is  thrust  forward  and  downward  like  the  keel 
of  a  boat,  the  lateral  compression  being  most  marked  at  the  junction  of 
the  ribs  and  the  cartilages.  This  deformity  is  almost  always  acquired 
(Fig.  142);  it  is  usually  an  effect  of  rhachitis  and  it  is  described  under 
that  heading.  It  may  be  induced  by  obstruction  of  respiration  caused 
by  enlarged  tonsils  and  the  like,  if  this  is  present  at  an  early  age.  It 
may  be  a  secondary  effect  of  the  sinking  forward  and  downward  of  the 

Fig.  142. 


General  rhachitic  distortions  and  pigeon  chest. 


upper  half  of  the  trunk  as  in  Pott's  disease  of  the  middle  of  the  spine. 

Treatment. — The  treatment  would  be  included  in  the  treatment  of 
the  affection  of  which  it  is  the  result.  The  tendency  in  rhachitic 
pigeon  chest  is  toward  spontaneous  cure ;  it  is  rarely  seen  in  adult  life. 

The  Funnel  Chest.     Synonym. — Pectus  Excavatum. 

This  deformity  when  well  marked  is  the  direct  opposite  of  the  keel 
(Fig.  143)  chest.  The  sternum  is  depressed  and  the  lateral  diameter  of 
the  thorax  is  correspondingly  increased.  The  milder  types  of  the  af- 
fection in  which  there  are  one  or  more  depressions  or  hollows  in  the 


188 


DEFORMITIES  OF  THE  CHEST. 


Fig.  143. 


sternum  are  common.     The  extreme  form,  in  which  the  entire  sternum 
is  depressed,  is  rare.     It  is  practically  always  a  congenital  deformity, 
and  it  is  not  susceptible  to  direct  treatment. 
.  Minor  Deformities  of  the  Chest. — As  has  been   stated,  distor- 
tions of  the  chest  secondary  to  de- 
formity of  the  spine  are  often  dis- 
covered before  the   original  cause 
is  suspected.     And  the  importance 
of  the  various  minor  irregularities 
of  the  chest  or  in  the  direction  of 
the   ribs   wdien   once   discovered  is 
often  exaggerated.     They  are  usu- 
ally the  result  of  preceding  rhachi- 
tis  and  no  especial  treatment  is  re- 
quired. 

Absence  of  Ribs. — Absence  or 
defective  formation  of  ribs  is  un- 
common. In  such  cases  there  is 
usually  defective  formation  of  the 
corresponding  muscles,  and  lateral 
curvature  of  the  spine  is  a  common 
accompaniment. 

Defective  Formation  of  the 
Pectoral  Muscles. — Several  in- 
stances in  which  one  or  both  of  the 
pectoral  muscles  were  defective  or 
absent,  have  been  observed  at  the 
Hospital  for  Ruptured  and  Crip- 
pled. The  malformation  in  these 
cases  caused  no  direct  symptoms. 

Absence  or  Defect  of  the  Clav- 
icle.— A  number  of  cases  of  defec- 
tive formation  of  the  clavicle  on  one 
or  both  sides  are  recorded.  In  most 
instances  a  portion  of  the  sternal  ex- 
tremity is  present.  The  defect  appears  to  cause  but  slight  inconvenience.^ 


Pectus  excavati^Q.     This  patient  has  ocular 
torticollis  also. 


Acquired  Luxation  or  Subluxation  of  the  Clavicle. 

Partial  displacement  of  the  sternal  end  of  the  clavicle  is  not  particu- 
larly uncommon.  In  some  instances  it  is  caused  by  injury ;  in  others 
no  cause  can  be  assigned.  Most  often  there  appears  to  be  a  laxity  of 
the  capsular  ligament  that  allows  a  displacement  during  certain  move- 
ments of  the  arm.  The  displacement  is  readily  reduced,  but  the 
weakness  and  insecurity  may  cause  discomfort  and  disability. 

Treatment. — In  some  instances  the  displacement  may  be  prevented 
by  the  pressure  of  a  pad  and  truss  spring,  attached  behind  to  the  corset 

'  Scliornstein   and  Cari  enter,  Lancet,  Jan.  7,  1899. 


ASYMMETRICAL  DEVELOPMENT. 


189 


or  braces  and  passing  over  the  shoulder  close  to  the  neck.  Such  an 
appliance  is  especially  useful  if  the  displacement  occurs  at  certain 
times  only,  as  in  dressing  the  hair,  playing  on  the  violin,  etc.  Cures 
are  reported  as  the  result  of  the  injection  of  alcohol  into  the  joint  from 
time  to  time,  and  Wolif  ^  has  operated  with  success  as  follows  :  The 
joint  is  opened  by  a  straight  incision.  A  fragment  of  bone  is  detached 
from  the  clavicle  above  and  a  similar  one  from  the  sternum  ;  these, 
still  adherent  to  the  periosteum,  are  overlapped  in  front  of  the  joint  and 
the  capsule  is  then  sutured. 

Asymmetrical   Development. 

In  normal  individuals  there  is  often  a  slight  difference  between  the 
two  halves  of  the  body  and  as  is  well  known,  inequality  in  the  length 
of  the  legs  is  not  at  all  uncommon.     Inequality  of  the  two  halves  of 

Fia.  144. 


Hypertrophy  of  the  right  forearm  and  hand,  due  to  congenital  ntevus. 

the  body  may  be  congenital  and  it  may  be  evident  at  birth,  but  usually 
it  does  not  attract  attention  until  adolescence.  In  many  instances  this 
inequality  is  a  slight  atrophy,  the  result  of  a  cerebral  hemiplegia  of  early 
childhood.  In  other  instances  the  inequality  may  be  due  to  congenital 
hypertrophy  that  may  affect  the  entire  limb.  In  such  cases  the  enlarge- 
^Cent.  fiir  Chir.,  Nov.  30,  1893. 


190 


THE  FUNCTIONAL  PATHOGENESIS  OF  DEFORMITY. 


ment  may  be  due  to  an  abnormal  amount  of  normal  tissue,  but  in  most 
instances  the  hypertrophy,  which  becomes  more  marked  with  the 
growth  of  the  child,  is  caused  by  an  abnormal  blood  supply,  a  form  of 
congenital  neevus.     (Fig.  144.) 

Tables  of  Weight,  Height  and  Circumference  of  the  Chest. — 

Boas. 


Pounds. 

Kilos. 

Height. 

Chest. 

In. 

Cm. 

In. 

Cm. 

Birth 

f  Male. 
\  Female. 

7.55 
7.16 

3.43 
3.26 

20.6 
20.5 

52.5 

52.2 

13.4 
13.0 

34.2 
33.2 

6  months 

r  Male. 
\  Female. 

16.0 

15.5 

7.26 
7.03 

25.4 

25.0 

64.8 
64.6 

16.5 
16.1 

42.0 
41.0 

1  year 

f  Male. 
\  Female. 

20.5 
19.8 

9.29 

8.84 

29.0 

28.7 

73.8 
73.2 

18.0 
17.4 

45.9 
44.4 

18  months 

f  Male. 
\  Female. 

22.8 
22.0 

10.35 
9.98 

30.0 
29.7 

76.3 
75.6 

18.5 
18.0 

47.1 
45.9 

2  years 

f  Male, 
t  Female. 

26.5 
25.5 

12.02 
11.56 

32.5 
32.5 

82.8 
82.8 

19.0 
18.5 

48.4 
47.0 

3  years 

f  Male. 
\  Female. 

31.2 

30.0 

14.14 
13.60 

35.0 
35.0 

89.1 
89.1 

20.1 
19.8 

51.1 
50.5 

4  years 

f  Male. 
\  Female. 

35.0 
34.0 

15.87 
15.41 

38.0 
38.0 

96.7 
96.7 

20.7 
20.5 

52.8 
52.2 

5  years 

f  Male. 
\  Female. 

41.2 
39.8 

18.71 
18.06 

41.7 
41.4 

106.8 
105.3 

21.5 

21.0 

54.8 
53.5 

6  years 

/Male. 
\  Female. 

45.1 
43.8 

20.48 
19.87 

44.1 
43.6 

112.0 
110.9 

23.2 

22.8 

59.1 

58.3 

7  years 

f  Male. 
\  Female. 

49.5 
48.0 

22.44 
21.78 

46.2 
45.9 

117.4 
116.7 

23.7 
23.3 

60.6 
59.5 

8  years 

r  Male. 
\  Female. 

54.5 
52.9 

24.70 
24.01 

48.2 
48.0 

122.3 
122.1 

24.4 
23.8 

62.2 
60.8 

9  years 

r  Male. 
\  Female. 

60.0 
57.5 

26.58 
26.10 

50.1 
49.6 

127.2 
126.0 

25.1 

24.5 

63.9 
62.5 

10  years 

f  Male. 
1  Female. 

66.6 
64.1 

30.22 
29.07 

52.2 
51.8 

132.6 
131.5 

25.8 
24.7 

65.6 
63.0 

11  years 

f  Male. 
\  Female. 

72.4 
70.3 

32.83 
31.87 

54.0 
53.8 

137.2 
136.6 

26.4 
25.8 

67.2 
65.8 

12  years 

f  Male. 
\  Female. 

79.8 
81.4 

36.21 
36.90 

55.8 
57.1 

141.7 
145.2 

27.0 

26.8 

68.8 
68.3 

13  years 

f  Male. 
1  Female. 

88.3 
91.2 

40.04 
41.36 

58.2 
58.7 

147.7 
149.2 

27.7 
28.0 

70.6 

71.3 

14  j^ears 

f  Male. 
\  Female. 

99.3 
100.3 

45.03 
45.50 

61.0 
60.3 

155.1 
153.2 

28.8 
29.2 

73.3 
74.1 

15  years 

f  Male, 
t  Female. 

110.08 
108.04 

50.26 
49.17 

63.0 
61.4 

159.9 
155.9 

30.0 
30.3 

76.6 
76.8 

THE   FUN(5TI0NAL  PATHOGENESIS   OF  DEFORMITY. 
WoUf  'S  Law. 

Mention  has  been  made,  and  will  be  made  again  from  time  to  time, 
of  the  adaptation  of  members  or  parts  to  abnormal  conditions,  and  of  the 
transformation  of  deformed  parts  to  the  normal  when  the  improper  re- 


WOLLF'S  LAW.  191 

lations  of  weight  and  strain  have  been  removed.  This  theory  or  law  of 
functional  adaptation  has  been  established  by  Professor  Julius  Wollf,  of 
Berlin,  who  has  shown  its  application  to  the  bones,  the  most  unyield- 
ing structures  of  the  body.  He  first  called  attention  to  the  fact  that 
the  shape  of  a  bone  is  the  effect  of  function.  It  is  the  effect  of  func- 
tion in  that  if  the  work  required  of  it  had  been  different,  its  shape 
would  have  been  different.  This  function  has  shaped  not  only  the 
external  contour  but  the  internal  structure  as  well.  If  a  bone  is 
broken,  for  example  the  neck  of  the  femur,  and  deformity  results,  the 
internal  architecture  is  no  longer  suitable  for  the  new  conditions  of 
weight  and  strain,  and  immediately  a  rearrangement  begins,  which 
finally  transforms  the  internal  structure,  not  only  in  the  neighbor- 
hood of  the  injury,  but  in  the  extremity  of  the  bone  also,  to  adapt 
the  deformed  part  as  well  as  may  be  to  the  work  that  is  now  de- 
manded of  it. 

The  normal  bone  is  braced  most  thoroughly,  and  is  most  resistant 
at  the  points  where  most  work  is  required  of  it.  If  the  weight  and 
strain  are  for  any  reason  transferred  to  another  part,  its  structure  be- 
comes hypertrophied  there,  and  correspondingly  weakened  at  the  point 
from  which  the  strain  has  been  removed.  With  this  change  in  the  in- 
ternal structure  a  change  in  the  external  contour  keeps  pace. 

For  the  further  exposition  of  this  theory  I  quote  from  Freiberg's  ^ 
review  and  abstract  of  Wollf's  ^  final  article. 

"  In  showing  that  improper  static  demands  made  upon  an  extremity 
resulted  in  the  formation  of  new  masses  of  bone  upon  the  surface  of 
the  bone  of  this  extremity,  or  that  they  produced  the  disappearance 
(atrophy)  of  bone  masses  according  to  the  nature  and  degree  of  these 
disturbances  in  static  requirements,  it  has  at  once  been  shown  in  what 
manner  deformities  have  their  origin.  For  these  transformations  on 
the  surface  of  bones  are  nothing  other  than  '  deformities '  in  the  wider 
or  narrower  sense  of  the  term. 

"  Taking  genu  valgum  or  habitual  scoliosis  as  example,  the  develop- 
ment of  a  deformity  in  the  narrow  sense  is  thus  explained.  In  the 
beginning  of  either  of  these  conditions  the  shape  of  the  bones  is  per- 
fectly normal.  As  the  result  of  excessive  fatigue  in  their  too  weak 
muscles  the  patients  are  frequently  assuming  a  faulty  position  of  limb 
or  body ;  they  seek  to  control  excessive  excursions  of  their  joints  by 
the  interference  of  the  articular  structures  themselves,  instead  of  by 
muscular  activity.  The  result  is  a  continual  alteration  in  the  static 
requirements  made  upon  the  bones  and  the  internal  architecture  ;  in- 
ternal and  external  configuration  of  the  bones  accommodate  themselves 
to  the  new  conditions.  Since,  according  to  this  reasoning,  deformities 
are  nothing  else  than  the  result  of  these  transformations  which  the  ex- 
ternal form  of  bones  or  joints  undergo  in  accommodating  itself  to 
faulty  demands  made  upon  them,  it  must  be  self-evident  that  these  de- 

'  Annals  of  Surgery,  July,  1897. 

2  Jul.  Wollf,  Die  Lehre  von  der  functionellen  Pathogenese  der  Deformitaten 
Archiv  fiir  klinische  Chirurgie,  Bd.  LIII.,  H.  4. 


192         THE  FUNCTIONAL  PATHOGENESIS  OF  DEFORMITY. 

formities  are  to  be  considered  pathological  only  in  the  sense  that  hy- 
pertrophy of  the  cardiac  muscle  in  valvular  insufficiency  is  pathological. 
That  which  is  really  pathological  is  only  the  altered  static  require- 
ments, the  abnormal  mechanical  function.  Far  from  being  pathological 
the  deformity  is  the  only  suitable  or  even  possible  form  by  means  of 
which  bone  or  joint  can  withstand  the  altered  forces  bearing  upon  it ; 
it  is  nature's  way  of  securing  the  greatest  possible  service  and  strength, 
under  the  new  conditions,  with  the  use  of  the  least  possible  amount  of 
material. 

' '  The  pathogenesis  of  deformities  is  therefore  functional.  Genu  val- 
gum, for  instance,  represents  only  the  functional  accommodation  of 
femur,  tibia,  and  knee-joint  to  the  improper  static  demands  made  by 
the  outward  deviation  of  the  leg.  Just  so  are  the  shapes  of  the  bones 
in  club-foot  the  expressions  of  similar  functional  accommodation  to  an 
inward  rotation  of  the  foot,  or  even,  sometimes,  an  inward  turning  of 
the  whole  lower  extremity.  The  faulty  position  of  an  extremity  under 
these  circumstances  is  to  be  regarded  rather  as  a  cause  of  the  deformity 
than  as  an  effect.  This  faulty  position  must  always  occupy  a  place 
intermediate  between  the  remote  causes  of  deformity  (hereditary  pre- 
disposition, habit,  muscular  weakness,  external  conditions  causing 
pressure  or  narrowing  space  for  growth)  and  the  anatomical  results 
which  these  various  remote  causes  bring  about. 

"  When  the  altered  demands  upon  an  extremity  do  not  occur  spon- 
taneously, as  in  the  above  instances,  but,  on  the  other  hand,  result  from 
a  primary  disturbance  in  the  shape  of  the  bones,  due  to  trauma  or 
bone-disease  with  consequent  softening  or  destruction  of  tissue,  there 
is  added  to  this  a  secondary  change  in  the  external  configuration  of  the 
bones,  and  there  is  thus  caused  a  '  deformity  in  the  broad  sense  of  the 
word.'  The  diiference  between  the  two  varieties  of  deformity,  there- 
fore, lies  only  in  the  addition  of  a  second  etiological  factor  (the  trauma, 
etc.)  to  the  deformity  in  the  broad  sense.  Both  varieties  liave  it  in 
common  that  the  shape  of  the  bones  and  joints  of  the  deformed  part 
represents  nothing  else  than  the  expression  of  a  functional  accommoda- 
tion to  the  faulty  static  demands  made  upon  it." 

"  As  a  second  example  by  means  of  which  to  explain  the  correctness 
of  the  doctrine  of  functional  pathogenesis  the  author  has  selected 
scoliosis.  In  the  first  chapter  the  author  showed  in  detail  that  the 
altered  conditions  in  the  length  and  height  of  the  transverse  processes 
of  scoliotic  vertebrae  as  well  as  corresponding  conditions  in  the  ribs  of 
the  scoliotic  thorax  are  so  evident  as  not  possibly  to  escape  notice,  and 
that  they  can  be  explained  in  no  other  way  than  as  functional  accom- 
modation to  the  circumstances  of  space,  changed  and  brought  about  by 
the  continual,  faulty,  and  cramped  position  of  the  thorax ;  this  is  as 
true  of  the  convex  as  of  the  concave  side  of  the  vertebral  column,  to 
which  the  transverse  processes  and  ribs  in  question  belong.  It  must 
be  manifest  that  changed  relations  of  one  part  of  the  skeleton  to  any 
other  part  of  the  skeleton  (as  far  as  space  conditions  are  concerned) 
necessarily  bring  about  changes  in  the  mechanical  demands  made  upon 


wo  LLP'S  LAW.  193 

this  part,  and  therefore  changes  in  the  directions  and  values  of  the 
pressure,  tension,  and  shearing  strains  of  each  and  every  point  in  this 
part  of  the  skeleton.  The  conclusion  thus  drawn,  that  accommodation 
to  space  means  the  same  as  accommodation  to  function,  is  of  greatest 
importance  to  the  general  doctrine  of  functional  accommodation. 

"  The  origin  of  the  wedge-shape  of  the  scoliotic  vertebra  now  comes 
under  discussion.  It  is  assumed  by  the  majority  of  writers  that  an 
abnormal  softness  of  the  bones  is  present  in  scoliosis  by  means  of 
which  a  faulty  position  can  model  the  bodies  of  the  vertebrae  as  it  does 
in  the  case  of  rachitic  disease  of  bone,  or  as  is  really  the  case  with  the 
intervertebral  discs  in  cases  of  '  habitual  scoliosis.'  While  unsup- 
ported by  any  pathologic-anatomical  investigations,  it  is  allowed  pos- 
sible, or  even  probable,  that  such  softness  of  the  bones  plays  a  role  in 
many  cases  of  scoliosis.  It  is  certain,  however,  that  this  is  by  no  means 
always  the  case  ;  as  evidenced  by  the  development  of  scoliosis  after 
empyema  in  adults,  and  the  great  exaggeration  in  adult  life  of  very 
slight  scolioses  originating  during  youth.  It  is  concluded,  on  the  con- 
trary, that  the  vertebra  may  acquire  its  scoliotic  w^edge  shape  entirely 
independent  of  the  pressure  of  the  superincumbent  weight.  Further- 
more, in  the  absence  of  any  abnormal  softness  of  the  bones,  the  body 
of  a  vertebra  may  lose  height  on  the  concave  side,  and  gain  the  same 
on  the  convex  side  through  the  '  tropic  stimulus  of  function  '  purely  ; 
being  simply  an  accommodation  to  the  diminished  space  on  the  concave 
side  and  increased  room  at  the  convexity  and  the  change  of  mechanical 
conditions  consequent  thereupon. 

"  This  simple  and  natural  conception  of  the  circumstances  concern- 
ing the  scoliotic  wedge  must  obtain  credence,  especially  since  the  old 
view,  corresponding  to  the  '  pressure  theory,'  has  been  long  ago  dis- 
proved by  HoflFa  and  Xicoladoni — namely,  that  the  concave  side  of  the 
Avedge  is  the  seat  of  atrophy,  and  that  this  atrophy  accounts  for  the 
loss  in  height  of  the  vertebral  body  on  this  side." 

The  imjjortance  of  Wollf's  theory  which  shows  how  deformity  may  be 
acquired  and  how  it  may  be  avoided,  is  very  evident.  It  is  of  equal 
importance  in  indicating  the  principles  of  treatment.  For  example, 
from  the  anatomical  description  of  a  club  foot  the  distortion  might 
appear  to  be  irremediable,  but  on  this  theory  one  feels  assured  that 
if  the  foot  can  be  fixed  for  a  sufficient  time  in  the  over-corrected  posi- 
tion, the  influence  of  the  new^  static  conditions  will  immediately  induce 
a  transformation,  not  only  in  soft  parts  but  in  the  bones  as  well,  that 
will  finally  effect  a  complete  and  absolute  cure.  So  also  the  correction 
of  a  distorted  bone  by  operative  means  is  at  best  but  imperfect ;  if 
however  the  static  conditions  have  been  changed,  nature  will  in  time 
reconstruct  the  entire  bone  so  perfectly  that,  in  a  few  years,  practically 
no  trace  of  the  former  distortion,  either  in  contour  or  internal  struc- 
ture, will  be  evident.  Scoliosis  might  be  cured  as  perfectly  as  the  club 
foot  or  the  bow  leg,  were  it  possible  to  restore  as  easily  the  normal 
conditions  of  weight  and  sti'ain. 
13 


CHAPTER  V. 

TUBERCULOUS  DISEASE  OF  THE  BONES 
AND  JOINTS. 

Etiology. — Three  factors  are  recognized  in  the  etiology  of  tubercu- 
lous disease  :  the  infectious  element  (the  tubercle  bacillus),  the  general 
predisposition  of  the  patient,  and  the  local  condition  that  favors  the 
reception  and  the  growth  of  the  bacilli. 

Predisposition. — The  predisposition,  both  general  and  local,  is 
spoken  of  as  lessened  vital  resistance.  A  general  predisposition  to  dis- 
ease may  be  inherited,  or  it  may  be  acquired.  Thus  a  history  of  tuber- 
culosis in  the  immediate  family  of  the  patient  is  supposed  to  imply  a 
lessened  resistance  to  this  form  of  disease.  In  a  certain  proportion, 
perhaps  25  per  cent,  of  the  cases,  this  inherited  predisposition  is  very 
direct  and  positive,  but  in  the  larger  number  the  family  history  is  as 
indefinite  as  in  a  similar  class  of  patients  under  treatment  for  any  other 
form  of  ailment.  The  acquired  predisposition  is  of  more  direct  impor- 
tance since  it  would  include  the  lowering  of  the  vitality  due  to  improper 
food  and  improper  hygienic  surroundings  of  every  variety,  together 
with  the  greater  liability  to  depressing  diseases  and  the  more  constant 
exposure  to  tuberculous  infection  that  such  conditions  imply.  Thus 
tuberculous  disease  of  the  bones,  as  well  as  of  other  parts,  is  more  com- 
mon among  the  poor  of  cities  than  among  the  more  favored  classes. 

Mode  of  Infectiox. — The  tubercle  bacilli  may  be  introduced  to 
the  body  by  inhalation  and  find  their  way  to  the  bronchial  glands,  or 
by  the  mouth  and  set  up  disease  in  the  mesenteric  glands,  or,  after  in- 
fection of  the  nasal  passage  or  neighboring  parts,  secondary  disease  of 
the  cervical  lymphatics  may  appear  in  the  so-called  scrofulous  glands 
of  the  neck. 

Latent  Tuberculosis. — It  may  be  assumed  that  disease  of  the 
bronchial  and  mesenteric  glands  is  not  uncommon  in  individuals  of 
apparently  perfect  health  since  it  is  often  discovered  at  autopsies  in 
those  who  have  died  from  other  causes.  This  form  of  glandular  dis- 
ease is  called  latent  tuberculosis  and  it  usually  precedes  a  local  outbreak 
in  the  bone  or  elsewhere.  In  many  instances  the  disease  may  remain 
latent  and  finally  disappear  or  it  may  persist  and  from  time  to  time  free 
bacilli  or  bits  of  infected  tissue  may  escape  into  the  blood  current ;  by 
it  they  are  deposited  in  other  parts,  where,  under  favoring  conditions, 
local  disease  may  be  set  up.  Depression  of  the  vitality  from  any  cause 
may  be  supposed  to  favor  the  progress  of  the  glandular  disease  which 
may  lead  to  a  dissemination  of  the  infectious  elements,  and  at  the  same 
time  it  may  lessen  the  resistance  of  other  tissues  that  may  be  exposed 


ETIOLOGY.  195 

to  the  infection.  This  accounts  for  the  well-known  influence  of  certain 
diseases^  such  as  measles  and  whooping-cough,  not  only  in  predisposing 
to  local  tuberculous  disease,  but  in  favoring  its  progress  when  it  is 
already  established.  It  is,  however,  possible  that  the  bacilli  that  have 
found  their  way  into  the  blood  current,  may  set  up  primary  disease  of 
a  bone  or  joint.  In  fact  it  is  stated  by  K5aig  ^  that  in  14  of  67  autop- 
sies on  subjects  who  had  suffered  from  tuberculous  disease  of  the  bones 
and  joints,  no  other  foci  were  found  in  the  body.  And  in  other  in- 
stances the  source  of  infection  may  be  preexistent  disease  of  the  lungs 
or  of  other  internal  organs. 

In  769  autopsies  on  children  under  twelve  years  of  age,  at  the 
Hospital  for  Children,  Great  Ormond  St.,  London,  reported  by  G.  F. 
Still,^  269  presented  tuberculous  lesions.  Of  these  269,  117  were  less 
than  two  years  of  age. 

The  apparent  channels  of  infection,  as  evidenced  by  the  appearance 
of  the  glandular  lesions,  were  as  follows  : 

Respiratory. 

Lungs 105 

Probably  lungs 33 

Ear 9 

Probably  ear 6 

153 — 57  per  cent. 

Alimentary. 

Intestines 53 

Probably  intestines 10 

63—23.4  per  cent. 

Other  Cases. 

Bones  or  joints 5 

Fauces 2 

Uncertain 46 

53 

Northrup  and  Bovaird  ^  have  made  similar  observations  at  the  N.  Y. 
Foundling  Hospital. 

Infection  by  respiratory  tract 148 

Infection  by  mesenteric  lympb  nodes 3 

Indeterminate 48 

200 

In  sixteen  instances  the  process  was  confined  to  the  bronchial  glands 
and  in  no  instance  were  these  glands  found  to  be  free  from  disease. 

Local  Predisposition. — The  local  conditions  that  favor  the  growth 
of  the  tubercle  bacilli  may  be  induced  by  injury.  Slight  injury  suffi- 
cient to  cause,  for  example,  a  hemorrhage  into  the  substance  of  the 

iDeutsch  Chir.,  L.  28a,  S.  157,  1900. 
2  British  Med.  Jour.,  August  19,  1899. 

"Northrup,  N.  Y.  Med.  Jour.,  February  21,  1891.  Bovaird,  N.  Y.  Med.  Jour., 
July  1,  1899. 


196      TUBERCULOUS  DISEASE  OF  THE  BONES  AND  JOINTS. 

cancellous  tissue,  induces  a  local  congestion  during  the  process  of  repair 
that  provides  the  proper  soil  for  the  growth  of  the  bacilli  when  they  are 
deposited  in  its  neighborhood.  This  has  been  proved  experimentally 
by  Krause  and  it  is  supported  by  clinical  evidence.  The  great  prepon- 
derance of  disease  in  the  lower  over  that  of  the  upper  extremities  in 
childhood  is  supposed  to  be  another  argument  in  favor  of  the  influence 
of  injury  in  the  causation  of  disease. 

In  271  of  1,156  cases  of  tuberculosis  of  the  bones  and  joints,  treated 
at  the  Clinics  at  Gottingen  and  Breslan,^  injury  seemed  to  be  a  di- 
rect predisposing  cause  of  the  local  disease,  twenty-three  per  cent.  A 
much  higher  percentage  than  this  has  been  assigned  by  other  writers, 
but  the  exact  relation  of  traumatism  to  disease  can  only  be  conjectured. 

The  seat  of  the  disease  is  almost  always  in  the  newly  formed  bone 
about  an  epiphyseal  cartilage.  This  tissue  is  vulnerable  ;  it  is  there- 
fore more  exposed  to  direct  injury;  it  is  subjected  also  to  the  strain 
of  motion  at  the  neighboring  joint,  and  as  the  circulation  is  here  more 
active  the  bacilli  are  more  often  deposited  in  this  situation. 

The  vulnerability  of  growing  bone  accounts  also  for  the  relative  fre- 
quency of  bone  disease  in  childhood,-  as  compared  with  adult  life.  In- 
jury not  only  causes  a  local  predisposition  to  disease,  but  it  favors  its 
progress  when  it  is  once  established. 

Distribution  of  the  Disease. — In  13,308  cases  of  tuberculous  disease 
of  the  bones  and  joints  treated  at  the  Hospital  for  Ruptured  and  Crip- 
pled the  distribution  was,  in  order  of  frequency,  as  follows  : 

Vertebrae 5, 662 42. 5  per  cent. 

Hip  Joint 4,048 30.5         " 

Other  Joints 3,598 27.0         " 

13,308 

In  a  total  of  3,561  cases  treated  at  the  Hospital  for  Ruptured  and 
Crippled  and  at  the  Vanderbilt  Clinic,  during  the  past  five  years,  the 
distribution  was  as  follows  : 

Vertebrae 1 ,432 40. 2  per  cent. 

Hip        Joint 1,123 31.5         " 

Knee        ''     699 19.6         " 

Ankle      "     196 5.5         " 

Elbow     "     62) 

Shoulder"     42  I 3.1         " 

Wrist       "     7) 

3^561 

Trunk 1,482 40.2  per  cent. 

Lower  Extremities 2,018 56.6         " 

Upper  ''  Ill 3.1         " 

The  correspondence  between  these  two  tables  of  statistics  is  striking 
and  the  number  of  cases  is  so  large  that  the  proportions  may  be  ac- 
cepted as  approximately  correct  as  applied  to  the  distribution  of  the 
disease  in  childhood. 

'  Krause,  Deutsch  Chir.,  L.  28a,  S.  161,  1900. 


ETIOLOGY.  197 

At  the  Boston  Children's  Hospital  in  a  period  of  twenty-five  years, 
1869-1B93,  3,820  cases  were  treated.^    The  distribution  was  as  follows  : 

Vertebrae 1,964 51.4  per  cent. 

Hip 1,402 36.7         " 

Ankle  300 7.8         " 

Knee 104 2.7         " 

Wrist 20] 

Shoulder 15  I 1.3         " 

Elbow 15  j 

3,820 

Trunk 1,964 51.4  per  cent. 

Lower  Extremities 1,806 47.2         " 

Upper  '' 50 1.3         " 

Side  Affected. — Disease  of  the  joints  is  slightly  more  common  on 
the  right  than  on  the  left  side  of  the  body.  At  the  Hospital  for  Rup- 
tured and  Crippled  the  proportions  in  the  cases  treated  during  the  past 
ten  years,  are  as  follows  : 

Hip — right 53  per  cent. 

Knee — right  55        " 

Ankle— right 50        " 

Shoulder— right 64       " 

Elbow— right 60       " 

It  has  been  stated  that  one  of  the  explanations  of  the  great  prepon- 
derance of  the  disease  of  the  lower  over  the  upper  extremity,  is  the 
greater  liability  to  injury.  The  same  explanation  has  been  advanced 
to  account  for  the  greater  frequency  of  disease  on  the  right  side,  which 
is  more  marked  in  the  upper  than  in  the  lower  extremity  because  the 
right  arm  is  more  liable  to  overwork  as  well  as  to  injury. 

Sex. — Tuberculous  disease  of  the  joints  is  somewhat  more  common 
among  males  than  females. 

Of  3,822  cases  of  Pott's  disease  treated  at  the  Hospital  for  Rup- 
tured and  Crippled,  2,037  or  53  per  cent,  were  in  males. 

Of  3,307  cases  of  disease  of  the  hip  joint  treated  at  the  same  insti- 
tution 1,731  or  52.3  per  cent,  were  in  males. 

Of  1,218  cases  of  disease  of  the  knee  joint,  combined  statistics  of 
Koenig  and  Gibney,  703  or  57.6  per  cent,  were  in  males. 

Age. — In  5,461  cases  of  tuberculous  disease  treated  at  the  Hospital 
for  Ruptured  and  Crippled,  about  seven-eighths  of  the  patients  were 
less  than  fourteen  years  of  age. 

i  Vertebrae 87.7  per  cent. 
Hip 88.2 
Other  joints.. 71. 7 


Between  14  and  21  years  of  (^^^^^^''^ J'^  P^^, 

^°® (  Other  joints..l0.7 


r  Vertebrae 4.5  per 

More  than  21  years  of  age \  Hip 2.5 

(  Other  joints..l7.5^ 
■  Report  of  the  Boston  Children's  Hospital.  ^  Knight,  Orthopedia. 


cent. 


cent. 


198      TUBERCULOUS  DISEASE  OF  THE  BONES  AND  JOINTS. 

Of  1,259  cases  of  Pott's  disease  treated  recently  at  the  same  insti- 
tution, 1,075,  85  per  cent,  of  the  patients  were  in  the  first  decade  ;  50 
per  cent,  were  three  to  five  years  of  age  inclusive  at  the  inception  of 
the  disease. 

In  1,000  cases  of  disease  of  the  hip  joint,  the  ages  of  the  patients 
correspond  closely  to  these,  87.2  per  cent,  were  in  the  first  decade  and 
45.2  per  cent,  were  from  three  to  five  years  of  age  inclusive. 

In  1,000  cases  of  disease  of  the  knee  joint,  75  per  cent,  were  in  the 
first  decade  and  40  per  cent,  were  from  three  to  five  years  inclusive. 

In  339  cases  of  disease  of  the  ankle  joint,  70  per  cent,  were  in  the 
first  decade  and  but  35  per  cent,  were  included  within  the  three  years. 

The  distribution  of  the  disease  and  its  relative  frequency  at  the  dif- 
ferent ages  is  shown  by  Alfer's  table  of  statistics  from  Trendelenburg's 
clinic  at  Bonn.^ 


0-5 

5-10 

10-15 

15-20 

20-25 

25-30 

30-35 

35-40 

40-45 

45-50 

50-55 

55-60 

60-65 

65-70  Total. 

Vertebrae 

Hip 

89 
58 
47 
5 
0 
7 
1 

59 

59 

52 

9 

2 

14 

0 

32 
43 
47 
10 

2 
14 

0 

23 

46 

37 

5 

6 

21 

1 

9 
9 

20 
2 
3 

12 
5 

10 

11 

11 

1 

5 
9 
0 

3 

6 
23 
1 
3 
6 
0 

6 

0 

11 

3 

1 

5 
3 

3 
4 
11 
2 
1 
9 
1 

1 
1 

3 
0 
2 
8 
3 

4 

1 

2 
3 

2 
5 

2 

0 

3 

8 
0 
1 
2 

1 

0 

0 
6 
2 
0 
2 
3 

0 
0 
3 

0 
0 
0 
0 

239 
241 

281 

Ankle 

43 

Shoulder 

Elbow 

28 
114 

Wrist 

20 

Total 

207 

195 

148 

159 

60 

47 

42 

29     31 

18 

19 

15 

13 

3 

966 

This  table  illustrates  the  well-known  fact  that  disease  of  the  upper 
extremity,  relatively  infrequent  at  all  ages,  is  proportionately  far  more 
common  in  adult  life  than  is  disease  of  the  lower  extremity.  Of  the 
joints  of  the  lower  extremity,  the  knee  and  the  ankle  are  proportion- 
ately more  often  diseased  in  later  life  than  is  the  hip. 

Pathology. — When  the  bacilli  are  deposited  in  a  part,  the  irritation 
of  their  toxines  causes  a  proliferation  of  the  fixed  cells  which  lie  in 
direct  contact  with  the  germs,  and  about  these  a  ring  of  leucocytes 
forms.  The  bacilli,  the  epithelioid  cells  including  often  one  or  more 
giant  cells,  together  with  the  surrounding  leucocytes,  constitute  the  vis- 
ible tubercle  of  bone,  a  minute  grayish  speck  in  the  cancellous  structure. 
The  central  cells  about  the  bacilli,  increasing  in  number,  deprived  of 
nourishment  and  poisoned  by  the  toxines,  die  and  are  disintegrated 
to  granular  material,  "  caseate,"  and  the  tubercle  changes  to  a  yellow 
color  ;  but  the  bacilli,  multiplying  and  escaping,  form  new  tubercles 
about  the  original  focus,  which  coalesce  as  the  area  of  the  disease  en- 
larges. Meanwhile  the  surrounding  tissue  becomes  congested,  as  the 
result  of  the  irritation,  and  the  fixed  cells  become  organized,  or  partly 
organized,  into  a  feeble,  ill-nourished  form  of  granulation  tissue,  rep- 
resenting the  effort  of  the  part  to  shut  out  and  to  expel  the  foreign  sub- 
stances formed  by  the  disease.  Or,  if  this  local  resistance  is  effective, 
the  cells  become  actually  organized  into  firm  granulations  which  sur- 
round and  destroy  the  germs,  and  then  are  farther  transformed  into 
'Beit,  ziirldin.  Cliir.,  1891,  Bd.  8,.  PI.  2. 


PATHOLOGY.  199 

scar  tissue.  But  in  most  instances  either  because  the  irritation  is  in- 
sufficient or  because  of  the  deficient  vitality  of  the  part,  the  granula- 
tions are  feeble  and  unstable  and  they  in  turn  become  infected  and  de- 
stroyed by  the  multiplying  bacilli,  thus  serving  only  to  extend  the 
area  of  the  disease.  This  granulation  tissue,  before  and  after  the 
stage  of  infection,  absorbs  and  destroys  the  bone.  If  the  progress  of 
the  disease  is  slow,  the  cancellous  structure  is  completely  absorbed  or 
is  represented  only  by  bone  sand,  but  if  the  disease  infiltrates  the  bone 
more  rapidly  it  may  destroy  its  vitality  while  its  structure  is  still  re- 
tained, and  a  sequestrum  is  formed.  Such  sequestra,  consisting  of 
rounded,  yellow,  crumbling  masses  of  cancellous  structure,  from  the 
size  of  a  pea  to  a  hazel  nut,  are  especially  common  in  epiphyseal  dis- 
ease of  childhood.  In  rare  instances,  wedge-shaped  sequestra  are 
found  with  the  base  at  the  periphery  of  the  epiphysis.  These  are  sup- 
posed to  be  caused  by  the  lodging  of  an  infected  embolus  in  a  terminal 
vessel,  which  causes  the  immediate  death  of  the  part  by  cutting  off  its 
blood  supply. 

By  the  formation  of  new  tubercles  at  the  periphery,  and  by  the 
caseation  of  material  in  the  center  of  the  diseased  area,  a  cavity  in 
the  bone  is  formed,  containing  the  debris  of  the  granulation  tissue  and 
often  sequestra  of  larger  or  smaller  size,  and  a  variable  amount  of  fluid, 
made  up  of  serum  and  leucocytes,  that  has  exuded  from  the  surround- 
ing granulations.  The  walls  of  this  cavity  are  formed  by  the  tissue 
in  which  the  disease  is  active  ;  the  inner  layer  containing  the  tubercles 
in  the  various  stages  of  formation  and  decay,  the  outer,  composed  of 
feeble,  ill-nourished,  granulation  tissue  as  yet  not  infected,  and  beyond 
this  the  softened  and  infiltrated  bone.  If  the  disease  has  ceased  to 
progress  in  any  direction,  the  granulations  contain  more  blood  ves- 
sels, they  are  of  firmer  consistency  and  more  perfectly  organized,  and 
the  substance  of  the  bone  is  harder,  showing  the  evidence  of  repair. 

One  termination  of  epiphyseal  disease  is  by  enclosure  of  the  focus  by 
resistant  granulations,  behind  which  the  bone  solidifies  and  shuts  in 
the  disease  or  in  favorable  cases  in  which  its  area  is  small,  completely 
absorbing  and  replacing  it  by  scar  tissue. 

Extra- ARTICULAR  Disease. — As  a  rule,  the  tendency  of  the  proc- 
ess is  to  expand  and  to  force  an  opening  through  the  cortex  of  the  bone 
to  the  exterior.  In  certain  cases  this  opening  may  form  outside  the 
capsule  of  the  joint,  and  through  it  the  products  of  the  disease  may  be 
discharged  into  the  overlying  tissues  forming  a  tuberculous  ab- 
scess. Here,  the  same  process  of  infection  and  extension  of  the  area 
of  disease  continues,  but  more  rapidly  than  when  it  was  confined  within 
the  bone ;  the  surfaces  of  the  muscles  and  fascia  are  infected  and  are 
covered  with  an  abscess  membrane  of  violet  or  grayish  yellow  color, 
made  up  of  tubercular  tissue  and  masses  of  fibrin,  lying  upon,  and 
loosely  attached  to,  the  outer  inflammatory  or  healthy  granulations. 

The  cavity  of  the  abscess  is  distended  with  tuberculous  pus  usually 
of  a  thin  consistency,  composed  of  serous  exudation,  leucocytes,  fibrin, 
masses  of  degenerated  tissue  and  fragments  of  bone  or  bone  sand.     It  is 


200      TUBERCULOUS  DISEASE  OF  THE  BONES  AND  JOINTS. 

commonly  of  a  Avhitish  color,  occasionally  reddish  from  mixture  with 
blood,  and  in  the  later  stages,  yellow  and  serous-like.  The  abscess  en- 
larges in  the  direction  of  least  resistance,  and  in  most  instances  finally 
perforates  the  skin  by  one  or  more  openings  through  which  its  con- 
tents are  discharged.  Or,  its  boundaries  may  cease  to  extend,  its  con- 
tents may  be  absorbed,  adhesions  may  form  between  its  walls,  and  a 
spontaneous  cure  is  effected.  This  course,  in  which  the  disease  remains 
extra-articular,  is  unusual.  It  is  more  common  at  those  joints  like 
the  knee,  elbow  and  ankle,  in  which  the  bones  are  superficial ;  it  is 
very  uncommon  at  the  hip  joint  and  it  is  practically  impossible  in  dis- 
ease of  the  spine. 

Peeforation  of  the  Joint. — Usually  the  tuberculous  process 
within  the  epiphysis,  enlarging  its  area,  comes  into  contact  with  car- 
tilage, and  perforating  this  finds  its  way  into  the  joint.  While  the 
disease  is  still  confined  within  the  bone,  the  tissues  within  the  joint  are 
involved  in  a  sympathetic  irritation  or  inflammation.  The  synovial 
membrane  becomes  congested  and  hypertrophied,  the  synovial  fluid  is 
increased  and  changed  in  quality,  fibrin  forms  and  is  deposited  upon 
the  cartilage  and  upon  the  lining  membrane  of  the  capsule.  It  is 
stated  by  Koenig  that  the  organization  of  these  fibrinous  deposits  upon 
the  cartilage  plays  an  important  part  in  its  destruction,  even  when 
actual  tuberculous  disease  is  absent.  As  a  result  of  the  sympathetic 
inflammation  within  the  joint,  adhesions  may  form  which  may  limit  the 
area  of  the  tuberculous  disease  and  retard  its  progress,  after  perfora- 
tion has  taken  place.  This  process  is  similar  to  the  inflammatory 
changes  in  the  pleura  caused  by  the  underlying  tuberculous  disease. 

When  the  disease  comes  into  contact  with  the  cartilage,  it  disinte- 
grates ;  the  tuberculous  granulations  breaking  through  and  spreading 
over  its  surface  destroy  it  in  piecemeal,  or  advancing  beneath  it, 
separate  it  from  the  bone  in  large,  necrotic  fragments.  The  synovial 
membrane  becomes  thickened  and  infiltrated,  numerous  tubercles  ap- 
pear upon  its  surface,  which  undergo  the  secondary  changes  that  have 
been  described,  and  the  joint  becomes,  practically  speaking,  an  abscess 
cavity.  The  surfaces  of  the  bones  are  disintegrated  by  the  disease 
and  the  destruction  is  hastened  by  the  pressure  and  friction  due^  to 
muscular  spasm  and  to  functional  use.  The  thickened  capsule,  distended 
by  the  fluid  and  solid  products  of  the  disease,  is  usually  perforated, 
and  a  secondary  abscess,  communicating  with  it,  is  formed  in  the  sur- 
rounding tissues.  As  results  of  the  disease,  secondary  changes  ap- 
pear in  the  neighboring  parts.  The  irritation  of  the  periosteum  may  in- 
duce the  formation  of  irregular  layers  of  bone  or  osteophytes  about  the 
joint.  A  new  formation  of  connective  tissue  proceeding  from  the 
layer  of  granulations  that  surround  the  disease  may  extend  to  the 
muscles  and  tendon  sheaths,  binding  them  together,  and  causing  limi- 
tation of  motion.  The  newly-formed  connective  tissue  may  be  very  vas- 
cular and  irregular  in  formation,  and  intermixed  with  it  may  be  masses 
of  gelatinous  or  myxomatous  tissue.  This,  according  to  Krause,  is  due  to 
the  venous  stasis  and  oedematous  infiltration  caused  by  the  pressure  of 


PATHOLOGY..  201 

the  capsular  contents  and  extra-capsular  proliferation  of  granulation  tis- 
sue. ,  These  changes  in  the  appearance  and  in  the  consistency  of  the  tis- 
sues about  the  joint  are  characteristic  of  the  so-called  white  swelling. 

Other  Forms  of  Tuberculous  Disease  of  Joints. — All  of  the  German 
writers  describe  forms  of  primary  synovial  disease,  its  frequency  varying 
from  16  to  35  per  cent,  of  the  cases.  It  is  more  common  in  adult  life 
than  in  childhood  and  at  the  knee  than  at  other  joints.  But  Mchols  ^ 
states  that  he  has  examined  120  tuberculous  joints,  and  has  found  in 
every  instance  one  or  more  foci  in  the  bone  that  apparently  preceded 
the  disease  in  the  joint. 

From  the  clinical  standpoint,  however,  one  must  recognize  a  form  of 
disease  in  which  the  symptoms  diifer  from  the  ordinary  osteal  type. 
It  begins  as  a  chronic  synovitis,  although  the  tissues  are  more  thickened 
and  infiltrated  than  in  simple  synovitis,  and  the  muscular  atrophy  is 
more  marked.  Reflex  spasm  and  limitation  of  motion  are  slight  and 
the  symptoms  are  rather  discomfort  and  fatigue  after  exertion  than  ac- 
tual pain.  After  many  months,  when  it  may  be  assumed  the  bones  are 
involved,  the  characteristic  symptoms  of  tuberculous  disease  appear. 
In  one  form  the  amount  of  effused  fluid  is  large,  and  is  clear  and  serous- 
like  in  character — hydrops  tuberculosus  ;  but  usually  it  is  cloudy,  and 
it  may  be  purulent  in  character. 

As  has  been  stated,  Koenig  lays  stress  upon  the  important  part 
played  by  fibrin  in  the  changes  that  take  place  within  a  joint.  Fibrin 
deposited  from  the  effused  fluid  forms  in  successive  layers  upon  the 
cartilage.  Into  this  fibrin,  vessels  grow  from  the  hypertrophied  and 
infected  synovial  membrane,  destroying  the  cartilage  together  with  the 
underlying  bone.  If  the  synovial  disease  is  primary,  the  bone  is  de- 
stroyed from  without,  but  if  it  is  secondary  to  epiphyseal  disease  it  is 
destroyed  from  within  also. 

Arborescent  Synovial  Tuberculosis. — In  this  form  the  interior  of  the 
joint  is  covered  with  villous  proliferations  from  the  synovial  membrane. 
These  are  formed,  it  is  supposed,  by  the  growth  of  blood  vessels  from  the 
membrane  into  the  layers  of  fibrin  that  are  deposited  upon  its  surface. 

Lipoma — Arborescens  Tuberculosum. — Arborescent  villous  prolifera- 
tions may  be  formed  of  adipose  tissue  covered  with  synovial  membrane 
which  project  into  the  joint. 

Rice  Bodies. — Rice  bodies  are  numerous  small  grayish-white  bodies 
resembling  cucumber  seeds,  that  are  found  in  certain  forms  of  synovial 
disease  and  particularly  in  tuberculosis  of  tendon  sheaths.  They  are 
formed  of  fragments  detached  from  the  proliferating  synovial  membrane 
and  possibly  of  simple  fibrin,  which,  under  the  influence  of  pressure 
and  attrition  in  the  movements  of  the  joint  or  of  the  tendon,  assume 
the  characteristic  shape  and  appearance.  These  bodies  within  a  tendon 
sheath  or  joint,  cause  a  peculiar  creaking,  perceptible  to  the  touch 
when  the  part  is  moved. 

Dry  Caries — Caries  Sicca. — In  this  form  of  disease,  which  is  said  to 
be  primarily  synovial,  there  is  but  little  formation  of  fluid  and  there  is 
J  Trans.  Am.  Orth.  Ass'n,  Vol.  XI. 


202      TUBERCULOUS  DISEASE  OF  THE  BONES  AND  JOINTS. 

but  little  tendency  toward  cheesy  degeneration  of  the  tuberculous  prod- 
ucts. The  infected  granulations  destroy  the  bone  without  forming 
sequestra,  and  usually  without  suppuration.  This  form  more  often  oc- 
curs at  the  shoulder  joint,  and  it  is  characterized  by  marked  limitation 
of  motion,  extreme  atrophy  of  the  surrounding  parts,  and  sometimes 
by  forward  displacement  of  the  partly  destroyed  head  of  the  humerus, 
that  may  be  mistaken  for  dislocation. 

Septic  Infection. — When  a  tuberculous  abscess  has  opened  sponta- 
neously, or  when  it  has  been  incised,  infection  with  pyogenic  germs  is 
common  and  it  occasionally  occurs  before  a  communication  with  the 
exterior  has  been  established.  After  such  infection  the  surrounding 
tissues  become  infiltrated,  reddened,  hot  and  sensitive  to  pressure.  The 
discharge  is  greatly  increased  in  quantity  and  changed  in  quality.  The 
local  pain  and  discomfort  are  aggravated  and  the  constitutional  effects 
of  pyogenic  infection  appear.  If  the  area  of  the  abscess  is  small  and 
if  the  drainage  is  efficient,  this  accident  is  of  slight  importance  and  it 
may  even  exercise  a  beneficial  effect  in  stimulating  the  circulation  and 
dissolving  the  effused  material  about  a  joint.  But  if  the  abscess  has 
burrowed  widely  into  surrounding  tissues  and  if  it  communicates  with 
an  important  joint,  it  is  a  dangerous  complication,  in  fact  the  greatest 
direct  danger  of  tuberculous  joint  disease.  The  persistent  suppuration 
exhausts  the  patient  and  induces  amyloid  degeneration  of  the  internal 
organs  ;  and  by  lessening  the  vital  resistance  it  favors  the  local  advance 
of  the  tuberculous  disease  and  its  general  dissemination. 

Repair. — Repair  in  tuberculous  disease  may  be  accomplished  by  the 
absorption,  ejection  or  enclosure  of  the  disease.  The  process  of  repair 
usually  accompanies  the  advance  of  the  destructive  process  and  ex- 
amples of  the  three  methods  of  cure  may  be  found  in  a  single  joint. 

The  curative  agent  is  the  granulation  tissue  which  forms  about  the 
area  of  disease  and  wdiich  finally  becoming  sufficiently  organized  to  resist 
the  infection  of  the  bacilli,  solidifies  into  fibrous  tissue.  In  those  cases 
in  which  the  disease  is  not  absorbed,  or  completely  thrown  off  in  the 
abscess  formation,  but  is  enclosed,  it  becomes  quiescent.  In  such  cases, 
under  the  influence  of  traumatism,  when  for  example  the  surrounding 
adhesions  are  broken  down  in  the  attempt  to  rectify  deformity  or  to 
overcome  anchylosis,  local  recurrence  of  the  disease  may  follow. 

Prognosis. — The  prognosis  will  be  considered  more  particularly  in 
the  sections  on  disease  of  special  parts.  The  danger  to  life  is  direct  and 
indirect,  and  this  varies  greatly  with  the  part  that  is  affected  and  with 
the  age  of  the  patient. 

In  disease  of  the  spine  the  direct  danger  to  life  is  greatest,  because 
of  its  situation  since  it  may  involve  the  spinal  cord  or  extend  to  the 
important  organs  in  the  neighlDorhood,  Abscess  may  in  rare  instances, 
merely  by  its  size  and  situation,  endanger  life  and  when  infected  it  is 
far  more  dangerous  because  of  the  difficulty  in  providing  efficient 
drainage.  The  influence  of  deformity  and  its  effect  in  compressing 
the  internal  organs  and  thus  interfering  with  the  vital  functions  is 
another  more  remote  element  of  dana^er  in  disease  in  this  situation. 


PBOGNOSIS.  203 

The  danger  to  life  from  disease  of  the  joints  is  in  proportion  to  their 
importance.  In  rare  instances  it  may  extend  to  the  shaft  of  the  bones 
and  set  up  an  extensive  osteomyelitis  ;  or  the  patient  may  be  weak- 
ened by  the  suffering  caused  by  active  disease,  but,  as  has  been 
stated,  the  most  direct  and  constant  danger  is  from  prolonged  suppu- 
ration that  follows  septic  infection.  Danger  from  this  source  is  much 
greater  at  the  hip  joint  than  at  the  ankle  or  elbow,  for  example,  be- 
cause of  the  greater  difficulty  in  preventing  the  burrowing  of  pus 
when  infection  has  occurred. 

The  indirect  danger  of  tuberculous  disease  is  its  dissemination  to 
more  important  organs.  But  it  by  no  means  follows  that  the  disease 
of  the  joint  is  the  source  of  the  general  infection. 

For  as  has  been  stated,  it  may  be  inferred  that  nearly  every  patient 
with  joint  disease  has  also  disease  of  the  lymphatic  glands,  and  in 
a  small  proportion  of  the  cases  there  may  be  also  active  disease  of 
important  organs.  Tuberculosis  of  the  lungs,  for  example,  is  often 
present  in  the  adult  before  the  local  outbreak  in  the  joint  appears,  and 
it  is  in  great  degree  because  of  this  liability  to  disease  of  the  lungs 
that  the  prognosis  of  joint  disease  becomes  progressively  worse  with 
the  age  of  the  patient. 

This  point  is  illustrated  by  the  statistics  of  Koenig  and  Bruns  on 
the  final  results  of  disease  of  the  knee  and  hip  joints,  to  which  atten- 
tion will  be  called  again  in  the  special  sections.  In  Koenig's  cases  of 
disease  of  the  knee  joint  the  death  rate  was  in  patients : 

Less  than  15  years  of  age 20  per  cent. 

From  16  to  30  years 24         " 

''       31to40     "     44         " 

More  than  40     " 60         '' 

In  Brun's  statistics,  the  death  rate  was  of  patients  in  the  first  decade  36 
per  cent. — in  the  second  decade  44  per  cent. — older  than  this  72  per  cent. 

The  cure  of  latent  tuberculosis  in  the  lymph  nodes  as  well  as  of 
active  disease  of  the  lungs  or  bones  depends  upon  the  vital  resistance 
of  the  patient.  This  vital  resistance  is  lessened  by  pain,  by  confinement 
and  lack  of  exercise.  It  is  directly  impaired  by  the  exhausting  suppu- 
ration and  by  the  poisoning  of  the  toxines  incidental  to  septic  infec- 
tion. Under  these  conditions  the  local  disease  advances  and  a  general 
dissemination  is  more  probable.  This  accounts  for  the  fact  that  death 
from  general  tuberculous  infection  is  much  more  common  in  this  class 
than  when  suppuration  has  been  slight  or  absent.  This  point  is  again 
illustrated  by  the  statistics  referred  to.  The  death  rate  in  the  cases  of 
disease  at  the  knee  without  abscess  was  twenty-five  per  cent.,  with  ab- 
scess forty-six  per  cent.  Death  rate  in  cases  of  disease  at  the  hip  with 
abscess  fifty-two  per  cent.,  without  abscess  twenty-three  per  cent. 

It  is  probable  that  tuberculosis  may  be  disseminated  by  operation 
upon  tuberculous  joints,  although  the  evidence  upon  this  point  is 
vague  and  conflicting.  Gibney,  contrasting  two  equal  periods  of  thir- 
teen years  of  service  at  the  Hospital  for  Ruptured  and  Crippled,  in  the 
first  of  which  no  operations  were  performed  on  tuberculous  subjects. 


204      TUBERCULOUS  DISEASE  OF  THE  BONES  AND  JOINTS. 

states  that  in  his  opinion  the  deaths  from  this  source  have  been  pro- 
portionately no  greater  during  the  period  of  active  surgical  interven- 
tion than  before.  And  an  investigation  of  the  causes  of  deaths  among 
the  patients  treated  at  the  X.  Y.  Orthopaedic  Dispensary  and  Hospi- 
tal during  a  period  of  twenty  years,  showed  that  at  least  twenty-five 
per  cent,  of  these  were  due  to  tuberculous  meningitis.^  During  this 
period  there  had  been,  practically  speaking,  no  operative  intervention, 
yet  the  proportion  of  deaths  from  this  cause  is  certainly  as  great  as  in 
any  statistics  that  have  been  reported.  It  would  appear  then  that  the 
danger  of  dissemination  is  not  sufficient  to  deter  one  from  performing 
any  operation  that  seems  to  be  indicated  by  the  local  disease  or  by  the 
general  condition  of  the  patient. 

Treatment. — From  what  has  been  stated  of  the  causes  of  disease  it 
follows  that  the  general  treatment  should  include,  if  possible,  a  change 
in  the  hygienic  conditions,  relief  from  the  danger  of  further  infection, 
pure  air  and  proper  food.  These  are  as  essential  in  the  treatment  of 
tuberculosis  of  the  bones  as  of  other  parts. 

As  far  as  the  cure  of  local  disease  is  concerned,  no  treatment  can  be 
as  effective  as  the  prompt  and  thorough  removal  of  the  focus  of  dis- 
ease, while  it  is  yet  limited  in  extent,  and  before  the  joint  has  become 
involved.  This  is  practicable,  however,  in  but  a  small  proportion  of 
the  cases  because  it  is  usually  impossible  to  locate  the  disease  accu- 
rately and  impossible  to  remove  it  wdthout  sacrificing  much  of  the 
healthy  bone  upon  which  the  future  usefulness  of  the  part  depends. 
At  one  time  early  operation,  even  complete  excision  of  the  joint,  was 
justified  on  the  plea  that  the  disease  might  thus  be  eradicated.  But 
now  that  it  is  known  that  in  nearly  all  cases  other  tuberculous  foci 
exist  in  the  body,  and  as  the  functional  results  after  these  early  opera- 
tions are  far  inferior  to  those  attained  under  conservative  treatment, 
early  excisions  are  limited  to  the  adolescent  or  adult  cases.  For  in 
this  class  growth  has  been  attained  and  the  economic  conditions  require 
that  the  period  of  disability  should  be  as  short  as  possible.  Local 
treatment  is  therefore  conducted  with  the  aim  of  relieving  the  part  of 
function,  that  is  to  say  from  strain  and  injury.  Functional  use  of  a 
diseased  joint  delays  natural  repair,  since  it  causes  pain  and  thus  re- 
duces the  natural  forces,  while  it  stimulates  the  disease  and  increases 
its  destructive  action.  The  details  of  treatment  wall  be  described  in 
the  consideration  of  disease  of  special  joints. 

Treatment  by  Drugs. — The  administration  of  drugs  occupies  a  very 
subordinate  place  in  treatment,  since  it  is  not  believed  that  any  drug 
exercises  a  direct  action  upon  the  local  disease  in  the  bone. 

Cod-liver  oil,  the  hypophosphites,  the  various  preparations  of  iron 
or  other  tonics  may  be  given  at  certain  times  with  benefit,  but  the  con- 
tinuous administration  of  medicine  during  the  years  that  are  required 
to  complete  a  cure  is,  of  course,  out  of  the  question. 

Local  Applications.  Iodoform. — Iodoform  is  supposed  to  exercise 
a  direct  germicidal  action  and  also  to  stimulate  the  formation  of  the  gran- 
'  Personal  communication  from  Dr.  David  Bovaird. 


TREATMENT.  205 

ulations  that  cast  off  or  absorb  the  tuberculous  products  and  then 
become  transformed  into  fibrous  tissue.  At  one  time  direct  injection 
of  the  remedy  into  the  bones  was  advocated,  but  this  has  now  been 
abandoned,  and  its  use  is  practically  limited  to  the  treatment  of  tuber- 
culous abscesses.  Iodoform  is  ordinarily  employed  in  an  emulsion  with 
glycerine  or  oil,  10  cc.  of  10  per  cent,  mixture  being  injected  at  inter- 
vals of  two  or  more  weeks.  Several  deaths  from  iodoform  poisoning 
have  been  reported,  but  injections  of  this  quantity  of  the  drug  are  ap- 
parently free  from  danger. 

Carbolic  Acid. — Carbolic  acid  in  dilute  solutions  was  at  one  time 
injected  into  tuberculous  cavities,  but  its  use  has  been  generally  dis- 
continued because  of  the  danger  of  poisoning.  Recently  Phelps  has 
advocated  the  use  of  pure  carbolic  acid  in  the  treatment  of  tubercu- 
lous abscesses  and  sinuses.  This  is  injected  into  the  fistulse  or  into 
the  abscess  cavity,  which  has  been  opened,  and  is  allowed  to  remain 
for  about  a  minute,  when  it  is  neutralized  by  copious  injections  of  al- 
cohol, after  which  the  part  is  thoroughly  cleansed  by  salt  solution. 
Carbolic  acid  doubtless  acts  as  a  caustic,  destroying  the  infected  gran- 
ulations and  stimulating  the  reparative  processes.  Other  remedies  of 
this  class,  for  example,  tincture  of  iodine,  chloride  of  zinc,  actual 
cautery  and  the  like,  are  also  used  and  in  certain  cases  with  benefit. 
In  the  treatment  of  tuberculous  ulcerations  ichthyol,  balsam  of  Peru 
and  iodoform  are  among  the  drugs  employed.  Balsam  of  Peru  dis- 
solved in  castor  oil  of  a  strength  of  about  10  per  cent,  as  suggested 
by  Van  Arsdale,  is  a  very  satisfactory  application. 

Venous  Stasis — Bier's  Treatment. — Bier's  treatment  of  tuberculous 
joint  disease  was  suggested  by  the  observation  of  Rokitanski,  that 
phthisis  was  uncommon  in  individuals  suffering  from  disease  of  the 
heart  when  the  mechanical  obstruction  was  sufficient  to  cause  venous 
congestion  of  the  lungs. 

This  treatment,  by  means  of  venous  stasis,  is  conducted  as  follows  : 
A  rubber  bandage  is  placed  about  the  limb  above  the  joint,  under  suffi- 
cient tension  to  interfere  with  the  return  of  the  venous  blood ;  and  in 
order  to  limit  the  congestion  to  the  diseased  part,  the  limb  is  firmly  band- 
aged with  a  flannel  bandage  up  to  the  joint,  from  below.  Between  the 
two  the  tissues  about  the  joint  become  swollen,  the  local  temperature  is 
increased  and  the  color  of  the  skin  becomes  bluish  red.  At  first  the 
congestion  is  continued  for  short  periods  only  during  the  day,  as  it  is 
somewhat  painful.  These  are  lengthened,  until  finally  it  may  be  ap- 
plied continuously. 

If  the  disease  is  active  the  treatment  may  hasten  abscess  formation, 
and  if  sinuses  are  present  the  discharge  is  usually  increased  for  a  time, 
The  venous  congestion  is  supposed  to  stimulate  the  formation  of  healthy 
granulations  and  their  further  transformation  into  fibrous  tissue ;  and 
according  to  the  investigations  of  Hamburger,  the  serum  of  venous 
blood  has  a  distinct  germicidal  property.  The  treatment  may  be  ap- 
plied most  conveniently  at  the  knee  and  ankle  joints,  but  if  applied  it 
should  serve  merely  as  an  adjunct  to  mechanical  protection. 


CHAPTER    VI 


XOX-TUBERCULOUS   DISEASES   OF   THE   JOINTS. 


Fig.  145. 


Syphilitic  Disease  of  the  Joints. 

In  early  ixfaxcy  the  characteristic  syphilitic  disease  of  the  bones 
is  a  form  of  osteochondritis.  Painful,  sensitive  swelHngs  appear  at 
the  epiphyseal  junctions,  either  as  small,  hard  tumors  or  as  general 
enlargements,  resembling  those  of  rhachitis.  (Fig.  145.)  As  a  rule 
several  epiphyses  are  involved,  more  often  those 
at  the  distal  extremities  of  the  bones  of  the  lower 
limbs,  and  in  these  cases  the  pain  and  discomfort 
may  induce  an  appearance  of  helplessness  of  the 
part  called  pseudo-paralysis.  (Parrot.)  In  osteo- 
chondritis there  is  a  multiplication  and  irregu- 
larity of  the  cartilage  cells  of  the  ossifying  layer 
and  premature  calcification.  As  a  result,  the  cir- 
culation is  insufficient  and  necrosis  of  a  part  of  the 
cartilage  may  follow,  which,  acting  as  a  foreign 
body,  sets  up  inflammatory 
changes  in  the  adjoining 
parts.  The  process  is 
shown  by  a  zone  of  hard, 
dry  yellow  substance  in  the 
ossifying  layer,  adjoining 
which  is  an  inflammation 
of  the  tissues  of  the  newly 
formed  bone  which  is  in 
part  transformed  to  granu- 
lation tissue.  If  the  dis- 
ease is  progressive  ulcera- 
tion and  suppuration  may 
follow,  the  cartilage  may  be 
destroyed  and  the  epijjliy- 
sis  may  be  separated  caus- 
ing deformity  and  cessation 
of  growth.  The  neighboring  joint  is  usually  involved  in  the  disease. 
In  the  milder  cases  there  is  a  simple  sympathetic  synovitis ;  in  the 
advanced  class  a  destructive  arthritis.  In  one  case  seen  recently,  the 
symptoms  of  pain  on  motion  combined  with  slight  effusion  into  several 
joints  were  present  without  the  epiphyseal  enlargement.  The  affection 
may  be  distinguished  from  rhachitis  by  the  accompanying  symptoms 


Suppurative  syphilitic  epiphysitis  at  lower  ends  of 
radius  and  tibia  in  an  infant  aged  one  month.  The  child 
died  shortly  after  the  drawings  were  made,  and  the  epi- 
physes were  found  lying  loose  in  purulent  cavities. 
(Tubby.  ) 


SYPHILITIC  DISEASE  OF  THE  JOINTS. 


207 


of  syphilis,  by  the  irregularity  of  the  epiphyseal  involvements  and  by 
the  age  of  the  patient  and  the  absence  of  the  other  symptoms  of  rhachitis. 

In  the  LATER  MAXIFESTATIOXS  OF  HEREDITARY  SYPHILIS,  in  which 

the  bones  in  the  neighborhood  of  the  joint  are  involved  in  syphilitic 
osteoperiostitis,  the  joint  may  be  sympathetically  aifected  or  the  disease 
may  actually  perforate  the  joint.  A  slow,  chronic,  infiltrating  gum- 
matous form  of  disease  appearing  in  later  childhood  may  simulate  very 
closely  the  appearances  of  so-called  white  swelling.  It  is  more  com- 
mon at  the  knee,  but  other  joints  are  often  affected  as  well. 


Fig.  146. 


Fig.  147 


.Syphilitic  osteo-periostitis  of  the  tibife  resembling  an- 
terior bow  leg.  This  is  the  most  characteristic  manifes- 
tation of  hereditary  syphilis. 


Syphilitic  disease. 


In  the  SECOXDARY  STAGE  OF  ACQUIRED  SYPHILIS,  pain  and  swell- 
ing of  the  joints,  resembling  rheumatism,  may  be  present,  and  in  ter- 
tiary syphilis  the  joint  may  be  involved  in  disease  of  the  neighboring 
bones,  or  the  joint  itself  may  be  primarily  implicated. 

In  most  instances  the  joint  affections  of  syphilis  are  explained  by 
the  history  and  by  the  other  signs  of  syphilitic  disease.  Spina  ventosa 
(Fig.  147),  Avhich  is  classed  as  one  of  the  evidences  of  syphilis,  is  far 


208  NON-TUBERCULOUS  DISEASES  OF  THE  JOINTS. 

more  commonly  of  tuberculous  origin,  as  is  illustrated  by  the  statistics 
of  Karewski/  of  157  cases,  in  which  but  three  were  due  to  syphilis. 

Syphilitic  disease  of  the  joints  is  very  uncommon  in  orthopaedic 
clinics  as  compared  with  those  of  tuberculous  origin.  This  is  as 
might  be  expected,  for  not  only  is  tuberculosis  far  more  common  than 
syphilis,  but  a  very  large  proportion,  according  to  Fournier,  77  per 
cent.,  of  the  syphilitic  children  are  born  dead  or  die  shortly  after  birth. 
Even  in  those  that  survive,  disease  of  the  bones  or  joints  in  the  form 
that  could  be  confounded  with  tuberculosis,  is  uncommon  as  compared 
with  its  other  manifestations. 

Some  writers  consider  hereditary  syphilis  to  be  a  very  important 
predisposing  cause  of  tuberculous  disease,  and  believe  that  many  cases 
classed  as  tuberculous  are  in  reality  syphilitic,  even  if  no  history  or 
confirmatory  signs  of  syphilis  be  present.  There  is  no  reliable  evi- 
dence to  support  this  view.  The  possibility  of  the  syphilitic  taint,  re- 
mote or  direct,  should  be  borne  in  mind,  and  in  doubtful  cases  appro- 
priate remedies  should  be  employed  ;  but  whether  the  disease  of  joint 
be  syphilitic  or  not  the  same  protective  treatment  is  indicated  that 
would  be  applied  under  other  circumstances. 

GONORRHCEAL  ARTHRITIS. 

Synonym.  Gonorrhceal  Rheumatism. — So-called  gonorrhoeal  rheu- 
matism is  an  inflammation  of  a  joint  caused  by  the  presence  of  gono- 
cocci.  It  is  said  to  complicate  from  two  to  five  per  cent,  of  all  the 
cases  of  gonorrhoea,  usually  appearing  in  the  later  stages  of  that  af- 
fection, and  it  is  more  common  among  those  who  are  in  a  debilitated 
condition. 

Distribution. — In  about  40  per  cent,  of  the  cases  it  is  monartic- 
ular and  the  knee  joint  is  most  often  involved.  In  375  cases  collected 
by  Finger,  the  distribution  was  as  follows  :  ^ 

Knee 136     Shoulder 24 

Ankle 59     Hip 18 

Wrist 43     Jaw 14 

Finger  joints 35     Other  articulations 21 

Elbow 25  375 

Bennecke  ^  has  tabulated  78  cases  recently  under  treatment.  The 
78  cases  occurred  in  56  patients,  of  whom  18  were  males,  38  females. 
The  distribution  was  as  follows  : 

Knee 31     Shoulder 4 

Hip 8     Elbow 10 

Ankle 9     Wrist 6 

Other  joints  of  foot 6     Fingers J^ 

78 
Symptoms. — The    affection    is    usually  of   a    subacute    character. 
The  joint  becomes  swollen  and  there  is  discomfort,  particularly  weak- 

1  Chir.  Krank.  des  Kindesalters. 

2  Taylor,  Ven.  Diseases,  p.  263. 

3 Die  Gon.  Gelenkentziindung  nach  beob.,  der  Chir.  Univ.  Klin,  in  der  K.  Charit^ 
zu  Berlin.     Hirschwald,  Berlin,  1899. 


GONORRHCEAL  ARTHRITIS. 


209 


Fig.  148. 


ness,  and  stiffness  on  use  ;  but  if  the  infection  is  more  severe  there 
may  be  local  heat,  pain  and  infiltration  of  the  tissues  with  accompany- 
ing muscular  spasm. 

Gonorrhoeal  arthritis  has  been  divided  into  three  classes  according 
to  its  symptoms  and  physical  characteristics :  The  serous ;  the  sero- 
fibrinous ;  the  purulent. 

The  SEROUS  FORM  is,  as 
its  name  implies,  a  simple 
effusion  resembling  other 
forms  of  subacute  synovitis, 
although  it  is  of  a  more 
chronic  character. 

The  SERO-FiBRiJsrous  va- 
riety is  of  a  more  serious 
character,  the  so-called  plas- 
tic type  of  inflammation.  In 
this  form  fibrin  may  be  de- 
posited upon  the  cartilage 
which  is  afterwards  organ- 
ized by  the  growth  of  vessels 
into  it  from  the  synovial 
membrane,  a  process  which 
erodes  the  cartilage  upon 
which  the  granulations  rest. 
The  folds  of  the  synovial 
membrane  adhere  to  one  an- 
other, the  capsule  is  thick- 
ened and  ligaments  and  ten- 
dons may  be  involved  in 
the  adhesive  inflammation. 
These  changes  within  and 
without  the  joint  may  se- 
riously impair  its  function 
after  the  cure  of  the  active 
disease. 

The   PURULENT    FORM    is 

uncommon  ;  it  is  similar  in 
its  characteristics  to  suppu- 
rative arthritis  from  other 
causes.     It  is  attended  by 

great  local  heat,  pain  and  swelling  and  by  constitutional  disturbance. 
In  orthopaedic  clinics  gonorrhoeal  arthritis  is  usually  seen  in  its  later 
stages  when  the  acute  symptoms  have  subsided.  In  these  cases,  swell- 
ing and  pain  persist,  in  many  instances,  and  in  the  more  severe 
class  motion  is  limited  or  the  limb  may  be  fixed  in  an  attitude  of 
deformity.  An  obstinate,  monarticular,  painful  swelling  of  a  joint 
suggests  gonorrhoea,  and  its  presence  or  absence  should  always  be  de- 
termined, since  the  effective  treatment  of  the  primary  cause  is  essential 
14 


Deformities  resulting  from  infectious  osteomyelitis. 


210 


NON-TUBERCULOUS  DISEASES  OF  THE  JOINTS. 


to  the  cure  of  the  secondary  aifection  of  the  joint.  The  same  statement 
is  true  of  painful,  persistent  affections  of  bursse  and  tendon  sheaths, 
and  of  obstinate  forms  of  weak  foot. 

Treatment. — The  treatment  of  the    early  stage  of  this  form  of 
arthritis  is  rest  and  compression  with  hot  or  cold  applications  as  may 
seem  to  be  indicated.     If  the  symptoms  are  acute  and  if  there  is  consti- 
tutional disturbance,  the  joint 
Fig.  149.  should  be  aspirated,  and  if  the 

examination  shows  the  effusion 
to  be  sero-purulent,  it  should 
be  treated  by  incision  and 
drainage.  In  the  chronic  form 
also,  when  the  capsule  is  dis- 
tended by  the  sero-fibrinous 
effusion,  incision  and  removal 
of  the  contents  is  indicated. 

In  the  latter  stages  of  disease 
of  the  ordinary  subacute  type, 
the  treatment  is  directed  to  the 
absorption  of  the  effused  ma- 
terial within  and  without  the 
joint,  and  to  the  restoration  of 
functional  activity.  The  use  of 
hot  air,  massage,  the  hot  and 
cold  douche  and  the  like  are  of 
service  in  stimulating  the  cir- 
culation. If  the  limb  has  be- 
come deformed,  and  if  it  be 
fixed  by  adhesions  and  by  con- 
tractions, the  distortion  may  be 
corrected  by  forcible  manipula- 
tion under  anaesthesia  which 
will  serve  to  rupture  the  adhe- 
sions as  well.  And  it  may  be  stated  that  this  class  of  cases  is  the  most 
encouraging  from  the  standpoint  of  restoration  of  function  by  this  means. 
If,  however,  the  limb  is  fixed  in  the  proper  position  it  is  well  to 
postpone  forcible  measures  until  the  effect  of  the  massage  and  gentle 
passive  movements  have  been  observed. 

Functional  use  is  the  most  effective  treatment,  and  this  is  made 
])ossible  by  the  employment  of  apparatus  by  which  the  exact  amount  of 
motion  that  the  joint  will  allow  without  discomfort,  may  be  permitted. 


Loss  of  growth  following  osteomyelitis  of  the  tibia. 


Other  Forms  of  Infectious  Arthritis. 

Puerperal  arthritis,  resembling  that  caused  by  gonorrhoea  may 
occur.  It  is  usually  of  a  more  severe  type  as  it  is  often  caused  by 
mixed  infection. 

Arthritis  Following  Ixfectious  Disease. — The  joints  may  be 


ACUTE  ARTHRITIS  OF  INFANCY.  211 

involved  in  the  course  of  any  infectious  disease.     A  mild    form  of 
arthritis  often  involving  several  joints,  is  particularly  common  after 

DIPHTHERIA  OR  SCARLATINA. 

Localized  and  destructive  forms  of  suppurative  arthritis  also  occur. 
Arthritis  following  typhoid  fever,  is  usually  of  a  severe  and  destruc- 
tive type.  Keen  ^  has  tabulated  84  cases.  In  43  per  cent,  of  these 
the  hip  joint  was  affected  and  in  40  per  cent,  spontaneous  dislocation 
occurred.  In  a  case  treated  recently  at  the  Hospital  for  Ruptured 
and  Crippled  there  had  been  a  destructive  arthritis  of  one  hip  joint, 
spontaneous  displacement  of  the  femur  on  the  other  side  and  secondary 
contractions  at  the  knees  and  ankles,  so  that  the  patient  was  bedridden. 

Treatment. — The  treatment  in  all  forms  of  arthritis  complicating 
diseases  of  this  class,  is  to  place  the  affected  joint  at  rest,  and  to  pre- 
vent the  secondary  distortions  that  lead  to  fixed  deformities. 

Spontaneous  dislocation  which  is  comparatively  common  when  the 
hip  joint  is  suddenly  distended  with  fluid,  is  not  likely  to  occur  unless 
the  limb  is  flexed  and  adducted.  This  attitude  should  be  prevented 
by  the  use  of  traction  or  support. 

The  presence  of  pus  is  of  course  an  indication  for  operative  inter- 
vention, and  in  all  doubtful  cases  the  character  of  the  effusion  should 
be  ascertained  by  aspiration. 


ACUTE    ARTHRITIS    OF    INFANCY. 

Acute  Epiphysitis. 

A  form  of  acute  suppurative  arthritis  primarily  within  the  joint  or 
more  often  secondary  to  disease  of  the  neighboring  epiphysis,  is  not 
uncommon  in  infancy. 

Etiology. — The  disease  may  be  caused  by  staphylococci,  or  strep- 
tococci, or  by  mixed  forms  of  infection.  In  the  early  weeks  of  life  it 
may  follow  infection  of  the  umbilicus.  It  may  be  secondary  to  one 
of  the  exanthemata  or  to  gonorrhoea,  but  in  many  instances  the  origin 
is  not  apparent.  Falls  or  blows  upon  the  part  appear  to  be  predis- 
posing causes. 

Townsend^  tabulated  seventy -three  cases  of  acute  arthritis,  eighteen 
of  which  were  personal  observations.  To  these  I  am  able  to  add 
twelve  others,  making  a  total  of  eighty-five  cases.  In  sixty-four  of 
these  the  infection  was  monarticular,  in  twenty-one  more  than  one 
joint  was  involved.     The  distribution  was  as  follows  : 

Hip  joint 45 53  per  cent. 

Knee  "     32 37        " 

Otherjoints 8 10        " 

The  sex  was  specified  in  sixty-one  cases.  Males,  thirty-eight ;  fe- 
males, twenty-three. 

1  Surgical  Complications  and  Sequels  to  Typhoid  Fever. 

2  Am.  Jour.  Med.  Sci.,  Jan.,  1890. 


212  NON-TUBERCULOUS  DISEASES  OF  THE  JOINTS. 

Symptoms. — If  the  infection  is  severe  there  is  immediate  local  heat^ 
redness,  swelling  and  oedema,  great  pain  and  corresponding  constitu- 
tional disturbance.  But  in  many  instances  the  local  and  general  symp- 
toms are  less  marked  and  several  weeks  may  elapse  before  the  patient 
is  brought  for  treatment. 

Treatment. — The  treatment  is  of  course  free  incision  and  drainage. 
The  part  must  be  supported  during  the  active  stage  of  the  disease  ;  an 
apparatus  is  usually  required  to  prevent  deformity  or  to  support  the 
weak  limb  when  the  patient  begins  to  walk. 

Prognosis. — If  the  arthritis  is  a  primary  disease  within  the  joint  com- 
plete recovery  may  follow  evacuation  of  the  pus,  but  as  a  rule  the  neigh- 
boring epiphyseal  junction  is  diseased,  suppuration  is  prolonged  and  a 
part  of  the  epiphysis  is  destroyed  before  the  disease  comes  to  an  end ; 
thus  subluxation  or  displacement  with  subsequent  deformity  and  loss  of 
growth  are  the  usual  results  of  this  form  of  disease.  At  the  hip  joint, 
for  example,  the  laxity  of  the  ligaments  and  the  upward  displacement 
of  the  femur  that  follow  destruction  of  the  head  of  the  bone,  cause 
symptoms  that  are  often  mistaken  for  those  of  congenital  dislocation. 

In  some  of  the  cases  there  is,  in  addition  to  the  arthritis,  an  osteo- 
mvelitis  of  the  shafts  of  one  or  more  of  the  bones.  These  cases  are 
usually  fatal,  or  if  the  patient  survives,  there  is  usually  necrosis  of  the 
affected  bones  and  consequently  extreme  deformity. 

In  the  cases  reported  by  Townsend  the  death  rate  was  in  the  monar- 
ticular form,  eighteen  per  cent.;  in  the  multiple  form,  seventy-three 
per  cent. 

Acute  Tuberculous  Arthritis. — In  early  infancy  forms  of  acute 
tuberculous  disease,  especially  at  the  knee  joint,  may  simulate  closely 
infectious  arthritis.  The  knee  may  be  swollen,  hot  and  sensitive  to 
pressure  and  the  onset  may  be  sudden  and  accompanied  by  constitu- 
tional disturbance.  Such  cases  are  more  often  observed  in  the  chil- 
dren of  mothers  in  whom  there  is  advanced  disease  of  the  lungs. 

Localized  Infectious  Osteomyelitis. 

In  older  subjects  localized  osteomyelitis  in  the  neighborhood  of  a 
joint  may  simulate  tuberculous  disease.  The  onset  of  the  affection  is 
however  more  abrupt,  the  surrounding  tissues  are  infiltrated  and  the 
symptoms  are  usually  more  acute  than  in  the  latter  affection.  In  such 
cases  operative  intervention  is  indicated. 

Osteo-arthritis. 

Synonyms. — ^^Arthritis  Deformans,  Rheumatoid  Arthritis. 

Osteo-arthritis  is  a  chronic  destructive  disease  of  the  joints  re- 
sembling rheumatism  somewhat  in  its  distribution  and  clinical  history. 

Pathology. — The  disease  appears  to  begin  in  the  cartilage  which 
becomes  fibrilated  and  destroyed  in  the  parts  subjected  to  greatest 
pressure,  while  it  is  thickened  and  heaped  up  into  irregular  layers  at  the 
periphery,  as  if  under  the  influence  of  pressure  it  had  been  squeezed  out 


OSTEO-ARTHRITIS. 


213 


from  the  interior  of  the  joint.  (Fig.  150.)  The  process  is  supposed  to 
consist,  in  a  multiplication  of  the  cartilage  cells  which  in  the  free  por- 
tion of  the  cartilage  escape  into  the  joint  while  in  those  parts  covered  by 
synovial  membrane  they  are  retained.  When  the  cartilage  disappears 
the  bone  deprived  of  its  natural  protection  is  worn  away,  and  under 
the  influence  of  pressure  and  friction  it  becomes  increased  in  density 
and  hardness,  "  eburuated."  Meanwhile  the  hypertrophied  cartilage 
at  the  periphery  becomes  in  part  ossified.  Thus  the  contour  of  the 
bones  and  their  mutual  relation  to  one  another  are  changed.  The 
synovial  membrane  becomes  hypertrophied  and  its  villi,  some  of  which 
may  contain  cartilaginous  no- 
dules, project  into  the  joint  in  ^^'^^-  l^*^- 
shaggy  fringes.  These  may  be 
detached  from  time  to  time  and 
may  form  loose  bodies  within 
the  capsule.  The  synovial 
fluid  may  be  greatly  increased 
in  quantity,  distending  the 
capsule  or,  communicating 
with  bursee,  it  may  form  cysts, 
as  is  sometimes  observed  at 
the  knee  joint.  But  more  com- 
monly the  fluid  is  decreased  in 
amount.  The  ligaments  are 
weakened  and  destroyed  and 
the  tendons  about  the  joint 
become  adherent  to  their 
sheaths  and  to  the  neighboring 
tissues.  The  muscles  atrophy 
and  become  contracted  and 
structurally  shortened  in  ac- 
commodation to  the  deformity. 

Etiology. — The  subject  is 
as  yet  very  imperfectly  under- 
stood, and  the  terms  osteo- 
arthritis and  rheumatoid  ar- 
thritis, which  are  usually  con- 
sidered as  synonymous,  probably  include  a  number  of  pathological  con- 
ditions. The  etiology  is  uncertain.  Malnutrition,  exposure  to  cold 
and  wet,  infectious  diseases  and  a  peculiar  condition  of  the  nervous 
system  are  considered  as  predisposing  causes,  and  recently  it  has  been 
claimed  that  the  disease  is  of  germicidal  origin,  but  this  is  doubtful. 
Injury  may  be  a  predisposing,  as  it  certainly  is  an  exciting,  cause  iji  the 
monarticular  form. 

Varieties. — Osteo-arthritis  may  be  divided,  from  the  clinical  stand- 
point, into  the  multiple  and  the  localized  forms. 

Multiple  osteo-aethritis  may  be  acute,  subacute  or  chronic. 

In  the  acute  variety  the  disease  may  resemble  rheumatism,  but  the 


Arthritis  deformans,  from  the  Museum  of  the  College 
of  Physicians  aud  Surgeons,  New  York. 


214  NON-TUBERCULOUS  DISEASES  OF  THE  JOINTS. 

ordinary  form  is  the  subacute  or  chronic,  which  may  progress  slowly, 
involving  one  joint  after  another  until  the  patient  may  be  crippled  by 
the  limitation  of  motion  in  the  joints,  and  by  the  secondary  distortion 
of  the  limbs. 

The  affection  is  far  more  common  among  females  than  males,  and  it 
usually  begins  in  early  middle  life,  although  it  is  not  particularly  in- 
frequent in  childhood.  In  one  case,  seen  at  the  Hospital  for  Ruptured 
and  Crippled,  the  patient  was  less  than  four  years  old,  and  several 
patients  have  been  treated  in  the  wards  who  were  less  than  ten  years 
of  age. 

In  500  cases  of  the  multiple  form  tabulated  by  Garrod,^  the  distri- 
bution was  as  follows  : 


The  hands 

n^ere 

involved 

in  86     pel 

■  cent. 

of  the 

cases, 

' '   knees 

ii 

"  60.6 

"   feet 

Cl 

"  34.4 

"   ankles 

it 

"  27.4 

' '   wrists 

li 

"  26.6 

' '   shoulders 

Cl 

''  25 

' '    elbows 

it 

"  25 

"   hips 

11 

"  14.6 

Temp.  max",  artic. 

25 

Cervical  spine 

35 

Dorsal  spine 

3 

Sterno-clavicular  ai 

■tic 

4 

Another  form  of  osteo-arthritis  of  comparatively  slight  importance  is 
that  in  which  the  disease  is  confined  to  the  joints  of  the  fingers.  The 
bases  of  one  or  more  of  the  distal  phalanges  become  enlarged  (He- 
berden's  nodosities)  and  the  fingers  become  somewhat  stiff  and  painful. 
Gradually  other  phalangeal  joints  become  involved  until  the  fingers 
become  deformed  and  function  is  somewhat  interfered  with,  although 
never  to  the  extent  that  is  observed  in  the  multiple  form  in  which  the 
fingers  are  dislocated  and  distorted. 

As  has  been  stated,  the  disease  is  usually  progressive,  periods  of 
quiescence  alternating  with  exacerbations  of  pain  and  discomfort,  at 
which  times  the  disease  progresses. 

The  Localized  Form. — The  localized  form  of  osteo-arthritis,  al- 
though similar  in  its  pathological  appearances,  differs  from  the  mul- 
tiple variety  in  that  it  is  more  common  in  men  than  in  women,  and 
that  injury  appears  to  have  a  distinct  influence  in  its  causation. 

The  affection  may  be  limited  to  one  of  the  large  joints,  the  hip,  the 
knee  or  the  shoulder,  while  the  hands,  that  are  almost  invariably  in- 
volved in  the  multiple  form,  remain  free  from  disease. 

The  Atrophic  Form. — In  the  description  of  the  pathology  of 
osteo-arthritis  it  has  been  stated  that  the  disease  is  characterized  by 
proliferation  of  cartilage,  and  by  hypertrophy  combined  with  destruc- 
tion of  the  bone.  There  is,  however,  another  variety  of  disease  re- 
sembling  this   form   closely   in  its   symptoms,  in  the  quality  of  the 

'Twentieth  Century  Practice. 


TREATMENT.  215 

patients  who  are  subject  to  it  and  in  its  distribution,  being  both  multi- 
ple and  monarticular,  but  differing  from  it  in  its  pathological  anatomy. 
In  this  form  there  is  no  hypertrophy  but  an  actual  atrophy  of  the  bone 
entering  into  the  formation  of  the  joint.  In  the  active  stage  of  the 
disease  the  joints  are  swollen,  infiltrated  and  thickened,  but  this 
thickening  is  practically  limited  to  the  soft  tissues  outside  the  joint, 
and  after  the  acute  stage  has  passed  the  stiffened  joints  may  be  actually 
smaller  than  before.  Thus  osteo-arthritis  includes  two  varieties  of  dis- 
ease from  the  standpoint  of  the  pathological  characteristics,  the  hyper- 
trophic and  the  atrophic. 

Gold th wait  ^  suggests  that  the  term  osteo-arthritis  might  be  limited 
to  the  hypertrophic  form,  while  the  other  variety,  characterized  by 
stiffening  of  the  joints  without  marked  destruction  or  lateral  displace- 
ment, might  be  classified  as  rheumatoid  arthritis.  It  is  doubtful, 
however,  if  a  sharp  distinction  can  be  drawn  between  the  two.  In 
childhood,  for  example,  there  may  be  great  destruction  and  displace- 
ment of  the  finger  joints  without  hypertrophy  which,  in  fact,  is  almost 
never  observed  in  this  class.  Again  in  the  early  stage  of  osteo-arthri- 
tis it  is  practically  impossible  to  distinguish  the  hypertrophic  from  the 
atrophic  form.  It  is  possible,  also,  that  the  two  varieties  may  be  com- 
bined in  the  same  individual,  or  that  either  form"  may  be  complicated 
by  ordinary  rheumatism. 

Symptoms. — The  symptoms  are  discomfort  and  pain  more  marked 
in  damp  weather  or  after  over-exertion  ;  stiffness  on  changing  from  rest 
to  activity  and  creaking  sensations  apparent  on  palpation.  Motion 
is  restricted  by  muscular  spasm  and  contraction  and  by  the  mechan- 
ical effects  of  the  disease  within  and  without  the  joint,  and  finally  the 
limb  may  become  fixed  in  an  attitude  of  deformity.  In  the  spine, 
the  deformity  is  usually  a  long  posterior  curvature  and  the  vertebrae 
are  firmly  fixed  by  growth  of  periosteal  bone,  or  if  the  cervical  region 
is  diseased  the  head  may  be  distorted.  (See  spondylitis  deformans.) 
At  the  hip  joint  there  is  wearing  away  of  the  head  of  the  bone  and 
upward  enlargement  of  the  acetabulum,  so  that  a  form  of  pathological 
coxa  vara  or  subluxation  appears,  and  the  limb  is  usually  somewhat 
flexed  and  adducted.  This  condition  is  sometimes  mistaken  for  frac- 
ture of  the  neck  of  the  femur,  especially  when  the  symptoms  have 
been  aggravated  by  injury.  A  similar  pathological  condition  may  oc- 
cur at  the  shoulder. 

Treatment. — The  treatment  should  be  directed  to  improving  the  gen- 
eral condition  of  the  patient  and  protecting  him  from  exposure  to  sudden 
changes  in  temperature.  Locally  the  disease  may  be  favorably  influ- 
enced by  massage,  by  hot  air,  by  static  electricity  and  the  like,  meas- 
ures which  doubtless  serve  to  improve  the  local  nutrition  and  thus  the 
resistance  of  the  affected  part.  The  application  of  the  actual  cautery 
and  the  protection  assured  by  flannel  bandages,  add  greatly  to  the  com- 
fort of  the  class  of  patients  seen  in  hospital  practice. 

If  deformity  is  present  it  may  be  overcome  if  necessary  by  forcible 
'  Boston  Med.  and  Surg.  Jour.,  Jan.,  1897. 


216 


NON-TUBERCULOUS  DISEASES  OF  THE  JOINTS. 


manipulation  under  anaesthesia,  after  which  the  improved  position  may 
be  assured  by  proper  apparatus.  This  treatment  is  much  more  useful, 
according  to  Goldthwait,  in  the  atrophic  than  in  the  hypertrophic  form 
of  the  disease.  In  cases  in  which  the  anchylosis  is  resistant  or  when 
the  joint  is  disabled  it  may  be  excised.  This  operation  has  been  per- 
formed with  success  at  the  knee ;  and  by  it  motion  has  been  restored 
at  the  elbow  in  cases  reported  by  Collinson,  Bannatyne  and  Southam.^ 
In  one  case  treated  at  the  Hospital  for  Ruptured  and  Crippled  the 
function  of  the  jaw  was  restored  completely  by  excision. 

In  the  localized  form,  apparatus  to  protect  the  part  from  strain  and 
injury  and  to  prevent  deformity,  is  sometimes  of  great  service.  And 
in  certain  instances  exploration  of  the  joint  which  would  permit  of  the 
removal  of  hypertrophied  tissue  might  be  of  service. 


Haemophilia — Hemarthrosis. 

Hemorrhage  into  a  joint  may  occur  in  a  so-called  "  bleeder."      In 
this  class,  practically  limited  to  the  male  sex,  the  knee  joint  is  most 

often  involved.     As  a  rule  it 
Fig.  151.  is  the  result  of  injury  and  if 

the  peculiarity  of  the  patient 
is  known,  the  nature  of  the 
effusion  may  be  suspected. 
In  some  instances  there  is  no 
history  of  traumatism  and 
the  swelling  may  be  accom- 
panied by  fever.  This  is 
probably  the  effect  of  the 
hemorrhage  rather  than  its 
cause. 

The  peculiar  interest  in 
the  affection,  aside  from  the 
importance  of  a  proper  diag- 
nosis, lies  in  the  fact  that  the 
further  organization  of  the 
effused  blood  may  cause 
symptoms,  and  changes  about 
the  joint,  that  may  be  mis- 
taken for  those  of  tubercu- 
lous disease.  There  may  be, 
for  example,  persistent  swell- 

Chareot's  disease  of  the  kuee  joint.  Jug^     thickening    of     the     tis- 

sues,  limitation  of  motion  and 
deformity  combined  with  more  or  less  weakness  and  discomfort.  These 
symptoms  are  explained  by  the  irritation  of  the  effused  blood  and  by 
its  further  absorption  and  organization  which  necessitates  the  formation 
and  growth  of  new  blood  vessels ;    practically  a  granulation  tissue  is 

1  Lancet,  Nov.  4  and  Dec.  9,  1899. 


CHARCOT'S  DISEASE.  217 

formed  that  may  erode  the  cartilage  upon  which  the  fibrinous  deposits 
rest.  These  secondary  changes  resemble  the  early  stage  of  osteo-arthritis. 
Treatment. — The  treatment  is  rest  and  protection.  Several  deaths 
have  been  reported  from  hemorrhage  after  operative  intervention  in 
cases  in  which  the  affection  had  been  mistaken  for  tuberculous  disease. 

Hemarthrosis. 

Hemorrhage  into  a  joint  caused  by  traumatism,  complicating  synovial 
effusion,  is  sometimes  followed  by  the  same  persistence  of  symptoms, 
and  it  may  be,  by  the  destructive  changes  that  result  from  the  effusion'in 
hemophilia.  This  suggests  the  advisability  of  incision  and  removal  of 
the  blood  clot,  in  order  to  relieve  the  part  of  this  unnecessary  process. 

Scorbutus — Scurvy. 

This  affection  is  sometimes  attended  with  hemorrhage  into  and  about 
the  joints.     It  will  be  considered  in  connection  with  infantile  rhachitis. 

Charcot's  Disease. 

Charcot's  disease  is  a  form  of  arthritis  which  is  secondary  to  loco- 
motor ataxia. 

Pathology. — It  resembles  somewhat  in  its  pathology  osteo-arthritis. 
The  cartilage  degenerates  and,  together  with  the  underlying  bone,  is 
worn  away  by  the  movements  of  the  limb.  Accompanying  the  destruc- 
tive process  there  is  an  exaggerated  and  irregular  formation  of  carti- 
lage and  bone  about  the  periphery  of  the  joint.  The  synovial  mem- 
brane is  hypertrophied  and  may  be  covered  in  places  with  calcareous 
plates  ;  the  contents  of  the  joint  is  usually  increased  in  quantity. 

The  joint  disease  usually  appears  early  in  the  course  of  locomotor 
ataxia  often  before  its  existence  is  suspected  and  it  is  sometimes  caused 
by  injury. 

Charcot's  disease  is  said  to  affect  from  five  to  ten  per  cent,  of  the 
ataxic  patients  ;  it  is  more  common  in  the  lower  extremity  and  one  or 
more  joints  may  be  involved.  In  the  cases  tabulated  by  Flatow  the 
distribution  was  as  follows  : 

Knee 60  ;  in  13  cases  both  knees. 

Foot 30;   "    9       "        "     feet. 

Hip 38;"    9       "        "     hips. 

Shoulder 27;   "    6       "        "     shoulders.» 

Symptoms. — The  symptoms  are  the  swelling  due  to  the  effusion, 
laxity  of  the  ligaments  and  deformity.  There  is  but  little  pain  and 
the  patient's  chief  complaint  is  of  the  weakness  and  distortion  of  the 
limb.  In  certain  cases  the  progress  of  the  affection  is  very  rapid  and 
the  destruction  of  bone  may  be  so  extensive  that  there  is  an  actual 
luxation  at  the  affected  joint. 

Diagnosis. — If  the  patient  is  known  to  have  locomotor  ataxia  the 
diagnosis  will  be  evident,  and  in  any  case  the  peculiar  enlargement 
iDtutsche  Chin,  L.  28,  1900. 


218  NON-TUBERCULOUS  DISEASES  OF  THE  JOINTS. 

and  thickening  of  the  tissues,  together  with  its  excessive  laxity  of  the 
ligaments,  characteristic  of  this  aifection,  which  has  been  called  a 
caricature  of  osteo- arthritis,  should  call  attention  to  the  disease  of  the 
spinal  cord. 

Treatment. — The  treatment  of  the  disease  is  efficient  support  (Fig. 
152)  for  the  joint,  to  prevent  progressive  distortion.  Excision  of  the 
knee  has  been  performed,  but  in  many  cases  the  bones  have  failed  to 
unite,  and  on  this  account  the  operation  is  contraindicated. 

Disease  of  joints  secondary  to  other  forms  of  disease  of  the 
NERVOUS  SYSTEM  may  occur.  It  is  most  common  as  a  complication  of 
syringomyelia,  in  which,  in  contrast  to  locomotor  ataxia,  the  joints  of 
the  upper  extremity  are  far  more  often  involved  than  of  the  lower. 

In  Schlesinger's  cases  the  distribution  was  as  follows  :  ^ 

Shoulder 29 

Elbow 24 

Wrist 18 

Hip 4 

Knee 7 

Foot 7 

Otherjoints 8 

97 

In  all  forms  of  joint  disease  secondary  to  disease  of  the  nervous 
system,  the  influence  of  injury  on  the  ill-nourished  or  ill-protected  part 
is  recognized  in  the  causation  and  in  the  progress  of  the  disease. 

This  indicates  the  principles  of  local  treatment. 

Anchylosis. 

Anchylosis  implies  fixation  in  an  attitude  of  deformity,  and  the  term 
should  be  restricted  to  practical  fixation  caused  by  tissue  changes 
within  or  without  a  joint,  but  it  is  often  incorrectly  applied  to  limita- 
tion of  motion  such  as  may  be  caused,  for  example,  by  muscular  spasm. 

Etiology  and  Pathology. — Anchylosis  may  be  the  result  of  actual 
union  of  two  bones  whose  cartilages  have  been  destroyed,  a  synostosis. 
This  is  sometimes  called  true,  as  distinguished  from  false  or  fibrous 
anchylosis. 

It  may  be  caused  by  adhesions  between  the  folds  of  synovial  mem- 
brane, by  adhesions  and  contractions  of  the  capsular  and  other  liga- 
ments, by  adhesions  between  the  tendons  and  their  sheaths,  by  the 
general  adhesions  and  contractions  caused  by  burrowing  abscesses 
and  by  the  retraction  and  structural  shortening  of  muscles  when 
the  deformity  has  persisted  for  a  sufficient  time.  It  may  be  caused 
also  by  fractures  or  dislocations  or  by  marginal  exostoses. 

Anchylosis  is  usually  secondary  to  an  inflammatory  affection  of  the 
joint  during  which  the  adhesions  have  formed,  within  and  without  the 
capsule,  and  if  deformity  has  been  allowed  to  persist  the  muscles  may 
have  become  atrophied  and  structurally  shortened  as  well. 

'  Die  Syringomyelie,  Wien,  1895. 


ANCHYLOSIS. 


219 


Prevention  and  Treatment. — The  danger  of  anchylosis  may  be 
lessened  by  the  proper  treatment  of  the  disease  of  which  it  is  a  result. 
In  tuberculous  disease,  for  example,  motion  may  be  preserved  in  many 
instances  by  efficient  protection,  by  which  the  area  of  the  disease  is 
restricted  and  its  destructive  effects 
checked.  In  this  class  of  cases  the  joint 
should  be  fixed,  during  the  progressive 
stage  of  the  disease,  in  the  attitude  in 

Fig.  152. 


Fig.  153. 


A  useful  form  of  brace  for  weak  knfee. 
Campbell  brace.     (Shaffer.) 


The 


Anchylosis  at  the  hip,  showiug 
masses  of  new  boue.  (From  the  Mu- 
seum of  the  College  of  Physicians 
and  Surgeons.) 


which  anchylosis,  if  it  be  unavoidable,  will  least  inconvenience  the  patient. 

Formerly  it  was  believed  that  prolonged  fixation  of  a  tuberculous 
joint  would  of  itself  induce  anchylosis,  but  now  that  it  is  known  that 
final  limitation  of  motion  is  dependent  upon  the  severity  and  the  dura- 
tion of  the  disease,  prolonged  rest  is  believed  to  be  the  most  efficient 
means  of  assuring  final  motion. 

In  this  class  of  cases,  when  the  disease  is  cured,  functional  use  will 


220  NOI^-TUBERCULOUS  DISEASES  OF  THE  JOINTS. 

ordinarily  restore  all  the  motion  of  which  the  part  is  capable.  In 
other  inflammatory  aifections  of  the  joint  which  are  usually  of  infectious 
origin,  the 'violence  of  the  acute  process  may  be  restrained  by  rest,  or 
by  the  removal  of  the  contents  of  the  joint  if  the  infection  is  severe. 

Passive  Motion. — When  the  acute  symptoms  have  subsided  the  ab- 
sorption of  the  plastic  material  may  be  hastened  by  massage,  the  hot  air 
bath  and  the  like,  and  by  carefully  regulated  passive  and  active  motion. 
In  the  final  stage,  when  there  is  no  longer  evidence  of  active  disease, 
passive  movements  under  anaesthesia  may  be  of  service  in  breaking 
adhesions,  especially  if  these  are  without  the  joint.  Passive  movements 
that  cause  persistent  discomfort  or  pain,  which  are  often  employed  in 
the  treatment  of  stiff  joints,  even  when  the  disease  is  active,  are  abso- 
lutely contraindicated.  If  however,  the  limb  during  the  course  of  the 
disease  has  become  deformed,  it  should  be  restored  to  its  proper  position 
as  soon  as  possible  even  though  force  is  required.  This  treatment  is  in- 
dicated in  order  to  prevent  secondary  retraction  of  the  muscles  and  fasciae. 

Forcible  Coreectiox. — The  class  of  cases,  in  which  the  limb  has 
become  fixed  in  deformity,  is  the  most  favorable  class  on  which  to  per- 
form so-called  brisement  force  because  the  rectification  of  deformity  is 
always  indicated,  and  in  accomplishing  this  there  is  always  the  pros- 
pect of  regaining  a  certain  degree  of  motion.  If,  however,  there  is  no 
deformity  the  advisability  of  forcible  motion  will  depend  on  the  char- 
acter of  the  preceding  disease,  as  well  as  upon  the  condition  of  the  joint. 
It  is  rarely  advisable  to  disturb  a  tuberculous  joint  or  at  least  not  until 
long  after  the  cure  of  the  disease,  but  if  the  anchylosis  has  followed 
infectious  arthritis  of  a  mild  form,  or  monarticular  rheumatism,  forci- 
ble manipulation  may  be  attempted.  If  under  gentle  manipulation  the 
adhesions  give  way  suddenly,  allowing  free  motion,  the  prognosis  is 
good,  but  if  there  be  a  peculiar  elastic  continuous  resistance,  as  when 
there  are  extensive  adhesions  within  the  joint,  there  is  little  likelihood 
of  attaining  motion  by  this  means.  If  but  slight  force  has  been  ex- 
erted there  is  usually  but  little  reaction,  and  massage  and  passive  motion 
may  be  employed  at  once ;  but  in  other  instances  the  manipulation  is 
followed  by  swelling  and  pain,  and  until  these  symptoms  have  subsided 
fixation  may  be  indicated.  Afterwards,  passive  movements  within  the 
range  that  is  practically  painless,  and  functional  use,  when  the  part  is 
protected  by  apparatus  which  limits  the  range  of  motion  to  the  painless 
area,  are  of  service.  The  X  ray  is  of  service  in  indicating  the  con- 
dition of  the  joint,  but  the  history  of  the  disease  and  the  physical  ex- 
amination which  shows  its  destructive  effects,  is  of  more  value.  In 
some  instances  operative  exploration  of  the  joint  may  be  indicated.. 
This  permits  the  removal  of  exostoses  or  displaced  fragments  of  bone 
after  fracture  that  may  limit  motion  mechanically.  True  bony  anchy- 
losis in  the  lower  extremity  admits  of  no  remedy  as  far  as  the  restor- 
ation of  joint  function  is  concerned,  although  the  symmetry  of  the  limb, 
if  it  be  deformed,  may  be  restored  by  osteotomy.  But  in  the  upper 
extremity,  motion  may  be  gained  by  excision  of  the  joint  and  in  some 
instances  this  is  advisable. 


CHAPTER    VII. 
TUBERCULOUS   DISEASE   OF   THE   HIP   JOINT. 

Synonyms. — Hip  Disease,  Morbus  Coxse. 

Hip  disease  is  a  chronic  destructive  disease  that  results  in  loss  of 
function  and  deformity.  At  one  time  a  number  of  pathological  proc- 
esses and  even  simple  deformity  (coxa  vara)  were  included  under  the 
title,  but  it  is  now  limited  to  tuberculous  disease. 

Pathology. — Tuberculous  disease  of  the  hip  joint  usually  begins  in 
several  minute  foci  in  the  neighborhood  of  the  epiphyseal  cartilage  of 
the  head  of  the  femur.     Here  the  circulation  is  most  active  and  here 

Fig.  154. 


Section  of  the  hip  joint  at  the  age  of  six  years.     (Schuchakdt.  ) 

the  newly  formed  bone  is  least  resistant.  Thus  the  bacilli,  darried  by 
the  blood,  are  more  often  deposited  at  this  point  where,  under  favoring 
conditions,  induced  it  may  be  by  slight  traumatisms,  the  disease  is  es- 
tablished. These  foci  coalesce  and  an  area  of  infected  granulations 
replaces  the  normal  structures.  If  the  local  resistance  is  sufficient,  the 
disease  may  be  confined  to  the  interior  of  the  bone,  but  in  most  in- 
stances it  gradually  forces  its  way  into  the  joint,  and  the  granulation 
tissue  spreading  under  and  over  the  cartilage,  destroys  it  in  its  progress. 
The  lining  membrane  of  the  joint  becomes  involved  in  the  disease  and 
finally  the  adjoining  surface  of  the  acetabulum  as  well.     In  a  certain 


DISEASE   OF  THE  HIP  JOINT. 


indeterminate  number  of  cases,  the  tuberculous  process  begins  about 
the  epiphyseal  junctions  in  the  acetabulum,  and  primary  disease  of  the 
synovial  membrane  may  occur,  although  this  is  certainly  uncommon  in 
childhood. 

From  the  clinical  standpoint,  primary  disease  of  the  acetabulum  may 
be  inferred  when  the  patient  is  particularly  susceptible  to  movements  of 
the  trunk,  or  when  lateral  pressure  on  the  pelvis  causes  pain  ;  or  when 
a  Roentgen  picture  shows  greater  erosion  of  the  acetabulum  than  of  the 
head  of  the  femur.  (Fig.  168.)  There  are  certain  cases  also,  in  which 
the  symptoms  of  the  disease  are  slight  and  in  which  the  swelling  of  the 
joint  is  well  marked ;  in  such  cases  it  is  probable  that  disease  of  the 

synovial    membrane  is   present, 
Fia.  155.  unaccompanied   by   marked  in- 

volvement of  the  head  of  the 
femur  or  of  the  acetabulum.  As 
a  rule,  however,  the  symptoms 
may  be  best  explained  by  pri- 
mary disease  of  the  head  of  the 
femur. 

While  the  tuberculous  process 
is  still  confined  within  the  bone, 
the  joint  shows  evidences  of 
sympathetic  irritation  ;  the  syno- 
vial membrane  is  congested  and 
the  fluid  within  the  joint  is 
increased  in  quantity.  These 
changes  become  more  marked 
as  the  disease  progresses,  the 
membrane  becomes  thickened 
and  granular,  and  adhesions  be- 
tween its  folds  lessen  the  capacity 
of  the  joint.  Thus,  if  the  ad- 
vance of  the  tuberculous  process 
has  been  retarded  by  efficient 
protection,  it  may  involve  but  a 
small  part  of  the  former  area  of 
the  joint  when  perforation  occurs. 
An  amount  of  tuberculous  fluid, 
large  enough  to  be  diagnosticated 
as  abscess,  is  present  in  about 
half  the  cases.  This  fluid  usually 
finds  an  exit  from  the  capsule  into  the  tissues  of  the  thigh,  but 
occasionally  it  may  pass  through  the  acetabulum  into  the  pelvic  cavity. 
In  rare  instances  the  disease  within  the  head  of  the  femur  may  not 
enter  the  joint,  but  may  make  an  opening  in  the  neck  outside  the  cap- 
sule, or  it  may  even  perforate  the  shaft  of  the  femur.  In  such  cases, 
the  joint  is,  in  most  instances,  finally  involved  unless  the  disease  is  re- 
moved by  surgical  means. 


'Wandering  of  the  acetabulum"   in  hip  disease. 
(Krause.    Deutsche  Chir.,  L.  28  a.) 


PATHOLOGY. 


223 


If  the  disease  involves  the  neck  of  the  bone  it  may  so  weaken  its 
structnre  that  the  angle  with  the  shaft  is  lessened,  a  form  of  coxa 
vara ;  or  the  head  of  the  bone  may  be  separated  at  the  epiphyseal  car- 
tilage, with  consequent  upward  displacement  of  the  trochanter. 

In  by  far  the  larger  number  of  cases  the  joint  is  perforated  and  the 
head  of  the  bone  and  the  acetabulum  are  involved  to  a  greater  or  less 
degree.  In  such  instances  the  destructive  effects  of  the  disease  are  in- 
creased by  the  pressure  and  friction  of  the  softened  bones  on  one 
another,  aggravated  by  the  spasm  of  the  surrounding  muscles.     Thus 

Fig.  156. 


Erosion  of  the  head  of  the  femur  and  of  the  upper  border  of  the  acetabulum.    Formation  of  new 
bone  (osteophytes)  about  the  acetabuUim. 


at  the  upper  margin  of  the  acetabulum  and  the  inner  and  upper  surface 
of  the  femur,  there  is  greater  loss  of  substance  than  elsewhere.  (Fig. 
156.) 

The  appearances  in  advanced  cases  of  this  type,  as  seen  at  operation 
or  autopsy,  may  be  summarized  somewhat  as  follows  :  The  head  of 
the  femur  is  deeply  eroded,  its  cartilaginous  covering  has  practically 
disappeared  or  is  in  part  still  adherent  in  necrotic  shreds.  It  lies  in 
sero-purulent  fluid,  surrounded  by  the  gelatinous  necrotic  granulations 
that  line  the  capsule  and  partly  fill  the  enlarged  acetabulum.  In  cer- 
tain instances  the  pelvic  bones  may  be  diseased  or  the  acetabulum  may 


224 


TUBERCULOUS  DISEASE   OF  THE  HIP  JOINT 


be  perforated  (Fig.  158),  or  the  shaft  of  the  femur  may  be  involved. 
Occasionally  the  disease  may  be  from  the  first  of  an  acute  destructive 
type  whose  course  is  but  little  influenced  by  treatment,  but  in  the  ma- 
jority of  cases  the  progress  of  the  disease,  and  its  destructive  effects, 
may  be  greatly  modified  by  protection  of  the  joint. 

In  the  natural  cure  of  the  disease  the  focus,  if  it  be  small,  may  be 
absorbed  and  replaced  by  scar-like  tissue  ;  or  the  products  of  the  dis- 
ease may  be  separated  from  the  healthy  parts,  and  discharged  by  ab- 
scess formation.  In  other  instances,  a  part  in  which  the  disease  is 
still  active  may  be  inclosed  within  the  newly  formed  tissue.     Here  the 


Fig.  157. 


Erosion  of  the  head  of  the  femur  and  of  the  upper  margin  of  the  acetabuhmi. 
spine ;  B,  anterior  inferior  spine. 


A,  anterior  superior 


process  may  remain  quiescent  or  it  may  cause  relapse,  many  years  after 
the  apparent  cure  of  the  disease.  Or  portions  of  necrosed  bone,  in- 
closed within  the  capsule,  may  prolong  suppuration  after  the  tubercu- 
lous disease  has  disappeared. 

Etiology. — The  etiology  of  tuberculous  disease  is  discussed  in  Chap- 
ter V. 

Relative  Frequency. — Tuberculous  disease  of  the  hip  joint  is  the 
most  common  and  the  most  important  of  the  affections  of  the  joints, 
ranking  second  to  Pott's  disease.  In  a  total  of  7,845  cases  of  tuber- 
culous disease  treated  in  the  out-patient  department  of  the  Hospital  for 
Ruptured  and  Crippled  during  the  past  fifteen  years,  1885-1899,  3,208 
were  Pott's  disease  ;  2,230  were  hip  disease,  while  the  remaining  2,408 
cases  included  all  the  other  joints. 


SYMPTOMS. 


225 


Age. — Hip  disease  is  essentially  a  disease  of  early  childhood,  although 
no  age  i§  exempt.  In  a  series  of  1,000  consecutive  cases  of  hip  dis- 
ease tabulated  for  me  by  Dr.  D.  D.  Ashley,  assistant  in  the  depart- 
ment, 88.1  per  cent,  of  the  patients  were  in  the  first  decade  of  life,  and 
45.6  per  cent,  of  these  were  from  three  to  five  years  of  age  inclusive. 


Age  at  Incipiency. 


Less  than  1 

year 

9 

Between  1  anc 

2 

vears 

39 

2 

3 

107 

3 

4 

155 

4 

5 

158 

5 

6 

139 

6 

7 

90 

7 

8 

51 

8 

9 

51 

9 

10 

40 

10 

11 

33 

11 

12 

19 

12 

13 

18 

13 

14 

23 

14 

15 

7 

15 

16 

8 

Between  16  and  17  years  11 


17 

18 

4 

18 

19 

5 

19 

20 

0 

20 

21 

3 

21 

22 

3 

22 

23 

1 

23 

24 

2 

24 

25 

3 

25 

26 

1 

26 

27 

1 

27 

28 

1 

28 

29 

1 

30 

33 

4 

33 

36 

1 

Age  not  stated 

12 

1,000 

Sex. — Sex  exercises  but  little  influence  although  the  disease  is 
slightly  more  common  among  males  than  among  females.  In  the 
1,000  cases  referred  to,  553  (55.3  per  cent.)  were  in  males,  447  were 
in  females. 

In  3,307  cases  treated  at  the  Fig.  ]58. 

same  institution,  53  per  cent, 
were  in  males. 

Side  Affected. — In  disease 
of  this  as  of  other  joints,  the 
right  is  somewhat  more  often 
affected  than  the  left.  In  the 
1,000  cases  506  were  on  the 
right  side,  483  were  on  the  left 
and  in  11  cases  both  joints 
were  involved.  In  a  larger 
number  of  cases  treated  in  the 
department,  53  per  cent,  were 
of  the  right  joint. 

Symptoms.  —  Tuberculous 
disease  of  the  hip  joint  is  a 
chronic,  insidious  affection 
characterized  by  occasional  ex- 
acerbations of  more  acute 
symptoms  that  are  induced  by 
over-strain  or  injury,  by  a  more 
rapid  advance  of  the  destructive  process,  or  by  infection  with  pyogenic 
germs.  In  the  early  stage  of  the  disease  the  joint  is  simply  sensitive, 
and  the  symptoms  vary  according  to  the  activity  of  the  disease,  which 
15 


Erosion  of  the  head  of  the  femur  and  destruction  of 
the  acetabulum. 


226  DISEASE  OF  THE  HIP  JOIST. 

may  increase  the  tension  within  the  bone  ;  the  susceptibility  of  the 
patient  and  the  strain  to  which  the  weakened  part  is  subjected.  This 
sensitiveness  is  shown  by  the  involuntary  adaptation  of  the  body  to 
the  weakness  of  the  affected  part,  or  as  popularly  expressed,  the  pa- 
tient favors  the  leg. 

The  important  symptoms  of  disease  of  the  hip  joint,  in  the  sense  of 
attracting  attention  to  the  affection,  are  pain  and  limp.  Of  the  two, 
pain  is  much  the  less  significant.  Hip  disease  is  by  no  means  a  pain- 
ful disease,  and  although  patients  are  often  brought  for  treatment  be- 
cause of  pain,  it  is  very  evident,  on  examination,  that  the  disease  must 
have  existed  long  before  the  acute  exacerbation  called  attention  to  its 
serious  character.  Even  in  cases  in  which  the  disease  is  far  advanced 
in  the  destructive  stage,  one  may  be  assured  that  the  patient  has  never 
complained  of  pain. 

Pain. — The  characteristic  pain  of  hip  disease  is  ''pain  in  the  knee," 
just  as  the  pain  of  Pott's  disease  is  referred  to  the  more  important 
distribution  of  the  nerves,  whose  filaments  are  irritated  by  the  local 
process.  The  hip  joint  is  supplied  by  the  anterior  crural,  the  sciatic 
and  obturator  nerves,  but  the  pain  is  more  often  referred  to  the  dis- 
tribution of  the  last,  thus  to  the  inner  side  of  the  knee.  Pain  so  per- 
sistently referred  to  the  knee  is  misleading,  and  patients  are  often 
treated  for  obscure  troubles  in  this  joint  long  after  an  examination 
of  the  hip  would  have  made  the  diagnosis  evident. 

Direct  local  pain  and  sensitiveness  at  the  hip  are  unusual,  unless 
the  disease  is  acute  in  character  or  unless  the  tissues  overlying  the 
joint  are  implicated,  as  in  abscess  formation.  The  pain  of  hip  disease 
is  induced  by  sudden  or  unguarded  movements,  or  by  injury  ;  therefore, 
in  many  instances,  it  is  rather  an  occasional  than  a  constant  symptom. 

Night  Cry. — Pain  at  night  is  of  importance,  as  it  more  often  attracts 
attention  than  the  occasional  complaint  of  discomfort  during  the  day. 
It  is  a  common  symptom  when  the  disease  is  at  all  acute  in  character 
and  it  is  often  present  when  pain,  during  the  period  of  activity,  is  ap- 
parently absent.  It  may  be  inferred,  as  an  explanation  of  this  symp- 
tom, that  the  joint  gradually  becomes  more  sensitive  under  the  strain 
of  use  during  the  day,  and  that  the  relaxation  of  the  voluntary  and  in- 
voluntary protection  of  the  muscles  allows  sudden  movements  that  ex- 
cite spasmodic  muscular  contractions,  which  force  the  sensitive  parts 
against  one  another.  This  causes  a  sharp  cry.  If  the  disease  is  acute, 
the  child  is  usually  awakened  and  is  found  holding  the  thigh  with  the 
hands  or  pressing  upon  the  limb  with  the  other  foot,  the  evidence  of 
pain  being  unmistakable.  In  the  less  sensitive  conditions  the  patient 
does  not  wake  after  crying  out,  but  simply  moans  or  is  restless  for  a 
time.  If  awakened  it  makes  no  complaint  of  pain  and  the  cry  is  sup- 
posed to  be  caused  by  a  "bad  dream."  This  cry  may  be  repeated 
several  times,  more  often  in  the  early  part  of  the  night. 

Limp. — The  limp  is  the  most  important  of  what  may  be  classed  as 
the  preliminary  signs  of  the  disease.  A  limp  is  a  change  in  the  rhythm 
of  the  gait,  a  long  step  alternating  with  a  shorter  step.     It  is  evident 


SYMPTOMS.  227 

that  any  interference  with  the  function  of  the  limb  will  cause  this  ir- 
regularity which  can  be  concealed  or  diminished  only  by  accommodat- 
ing the  normal  member  to  its  disabled  fellow.  Thus  an  inequality  in 
length,  or  a  limitation  of  motion  in  the  joint,  or  distortion  or  weak- 
ness or  pain,  may  cause  an  irregular  gait,  and  several  of  these  factors 
may  be  combined  in  the  causation  of  the  final  disability  of  hip  disease  ; 
but  in  the  early  stage  the  limp  is  due  rather  to  sensitiveness  than  to 
any  marked  restriction  of  function.  Thus  the  patient  favors  the  joint 
by  resting  on  the  limb  for  a  shorter  time  than  on  its  fellow,  and  by 
bearing  more  weight  upon  the  front  of  the  foot  than  upon  the  heel. 
If  the  joint  is  more  sensitive,  the  patient  may  bear  practically  all  the 
weight  upon  the  front  of  the  foot,  slight  plantar  flexion  at  the  ankle 
being  combined  with  slight  flexion  at  the  knee  and  hip  ;  thus  the  jar 
of  direct  impact  of  the  heel  upon  an  extended  leg,  is  avoided. 

The  limp  is  a  very  constant  symptom  of  hip  disease  that  is  more  or 
less  noticeable  according  to  the  character  of  the  disease  ;  it  is  even 
subject  to  daily  variations  in  the  same  patient,  being,  as  a  rule,  more 
apparent  in  the  morning  or  on  changing  from  an  attitude  of  rest,  than 
during  activity.  In  the  early  stage  of  the  disease  the  limp  may  be  even 
intermittent,  although  it  is  probable  that  in  most  instances  some  change 
from  the  normal  gait  might  be  detected  by  a  practiced  eye. 

The  other  symptoms  of  disease  of  the  hip  joint  are  more  properly 
physical  signs  that  become  evident  on  examination.  These  are  : 
Stiffness,  distortion,  change  of  contour  of  the  hip,  atrophy. 

Stiffness,  due  to  reflex  muscular  spasm,  is  by  far  the  most  impor- 
tant sign  of  the  disease.  It  is  the  instinctive  expression  of  the  in- 
ability of  the  joint  to  perform  its  full  function  and  especially  to  al- 
low the  full  range  of  motion  which  puts  more  strain  upon  the  bones 
and  the  other  components  of  the  joint.  It  is  the  first  and  the  last 
sign  of  disease ;  it  probably  precedes  the  limp  and  it  remains  long 
after  pain  has  ceased  to  be  a  symptom,  and  until  repair  is  complete. 

Reflex  muscular  spasm  limits  motion  in  every  direction  to  a  greater 
or  less  degree.  In  the  early  stage  of  the  disease  the  motion,  whether 
voluntary  or  passive,  may  be  perfectly  free  throughout  three-fourths  of 
its  normal  range,  but  when  the  limit  allowed  by  the  muscular  protec- 
tion is  reached,  motion  is  checked  by  a  peculiar  elastic  resistance.  If 
an  attempt  is  made  to  force  the  limb  beyond  the  limit  in  any  direc- 
tion, the  entire  body  follows  the  movement.  The  contraction  of  the 
surrounding  muscles,  including  those  of  the  trunk  even,  may  be  ap- 
preciated by  the  eye  and  by  the  hand,  and  the  expression  of  the  pa- 
tient's face  shows  that  the  manipulation  causes  discomfort. 

The  degree  of  muscular  spasm  is  in  proportion  to  the  sensitiveness 
of  the  joint  rather  than  to  the  area  of  the  destructive  disease.  Thus 
it  may  vary  from  day  to  day  and  even  from  hour  to  hour,  and  in  the 
acute  exacerbations  of  the  disease  motion  may  be  for  a  time  so  abso- 
lutely restricted  as  to  simulate  anchylosis. 

Reflex  muscular  spasm  is  an  infallible  sign  of  a  sensitive  joint ;  it 
is,  of  course,  a  symptom  not  confined  to  the  tuberculous  process,  but 


228 


TUBERCULOUS  DISEASE  OF  THE  HIP  JOINT. 


unless  it  be  the  direct  effect  of  injury  it  shows  the  presence  of  disease, 
and  if  this  disease  be  chronic  and  confined  to  a  single  joint  it  is,  in 
childhood  at  least,  almost  always  tuberculous  in  character.  In  the 
early  stage  of  hip  disease  the  restriction  of  motion  is  caused  almost 
entirely  by  reflex  muscular  spasm,  as  is  shown  by  the  fact  that  when 
the  patient  is  anaesthetized  the  range  of  motion  becomes  practically 

Fig.  159. 


The  stage  of  apparent  lengthening.      Fixed  abduction  of  45°.    When  the  anterior  superior  spines 
are  on  the  same  plane,  as  in  the  illustration,  the  deformity  is  evident.    (See  Fig.  160. ; 

free.     In  the  later  stages,  however,  motion  is  still  further  restrained 
by  adhesions  and  contractions,  within  and  without  the  joint. 

Distortion  of  the  Limb. — Persistent  reflex  muscular  spasm  is  always 
accompanied  by  a  certain  change  in  the  attitude  of  the  limb,  slight 
flexion  being  the  earliest  indication  of  distortion  in  disease  of  the  hip, 
as  at  every  other  joint.  With  this  flexion  there  is  usually  abduction 
and  slight  outward  rotation  of  the  limb. 


SYMPTOMS. 


229 


Flexiox,  AbductiojST  and  Outward  Rotation  —  Apparent 
Lengthening. — This  is  the  passive  attitude  or  the  attitude  of  rest 
in  the  normal  condition,  and  in  disease  it  shows  the  instinctive  adap- 
tation of  the  limb  to  a  sensitive  joint  which  is  still  capable  of  a  certain 
amount  of  work.  The  limb,  although  still  in  use,  is  reduced  in  activity, 
the  flexion  lessens  the  direct  jar  and  the  abduction  throws  the  limb  aside, 


Fig.  160. 


Fig.  161. 


stage  of  apparent  lengtheuing.  When 
the  distorted  limb  is  brought  to  the  median 
line  the  pelvis  is  so  tilted  that  the  abducted 
leg  seems  longer.     (See  Fig.  159.) 


Right  angle  flexion  in  hip  disease  partly 
concealed  by  the  compensatory  lordosis,  and 
by  the  flexion  at  the  knee  and  ankle. 


as  it  were,  from  the  active  attitude,  making  it  a  prop  and  adjunct 
of  its  fellow  instead  of  an  active  aid  in  the  propulsion  of  the  body. 
This  attitude  is  not  voluntarily  assumed  by  the  patient ;  it  is  involun- 
tary and  persistent.  It  is  sometimes  called  the  stage  of  apparent  length- 
ening. The  leg  seems  longer  than  its  fellow  because  it  is  held  away 
from  the  axis  of  the  body,  and  in  order  to  bring  it  into  the  middle  line 


230 


TUBERCULOUS  DISEASE  OF  THE  HIP  JOINT. 


and  parallel  to  its  fellow,  the  pelvis  must  be  tilted  downward  on  the 
diseased  side,  and  upward  on  the  other.  The  sound  leg  is  drawn  upward 
and  the  affected  leg  is  lowered  to  a  degree  corresponding  to  the  amount 
of  abduction.  (Fig.  160.)  If,  however,  the  anterior  superior  spines  of 
the  pelvis  be  placed  upon  the  same  plane,  the  distortion  becomes  evi- 
dent. (Fig.  159.)  Thus  the  deformity  of  the  limb  is  concealed  or 
compensated  by  a  tilting  of  the  pelvis  which  twists  the  lumbar  spine 
into  a  lateral  convexity,  toward  the  lower  side. 

In  the  same  manner  the  persistent  flexion  of  the  leg  is  concealed  by 
a  tilting  of  the  pelvis  forward,  and  by  an  increased  hollowness  or 
lordosis  of  the  lumbar  region.  (Fig.  161.)  Normally,  in  childhood  at 
least,  the  lumbar  spine  and  the  popliteal  surface  of  the  knee  should  touch 
the  table  when  the  patient  lies  upon  his  back,  but  if  the  leg  is  fixed  in 
flexion,  the  lumbar  region  must  be  arched  and  raised  from  the  table 
when  the  leg  rests  upon  it.     Thus,  in  order  to  make  the  flexion  appar- 

FiG.  162. 


The  degree  of  fixed  flexion  is  shown  when  the  lumbar  spine  is  held  in  contact  with  the  table  by 

flexing  the  other  thigh. 


ent,  the  lumbar  spine  must  be  forced  to  touch  the  table,  and  this  is 
possible  only  when  the  leg  is  raised  to  a  degree  corresponding  to  the 
deformity.  (Fig.  162.)  If  the  spine  were  rigid,  as  in  advanced  cases 
of  rheumatoid  arthritis,  this  compensation  would  be  impossible,  and  if 
the  patient  were  placed  upon  his  back  the  leg  could  not  be  brought 
down  to  the  table  ;  or  if  both  limbs  were  distorted,  as  is  sometimes 
the  case  when  both  hip  joints  are  diseased,  the  limbs  would  be  widely 
separated  or  crossed  over  one  another,  according  as  the  deformity  were 
in  abduction  or  adduction. 

Flexiox,  Adduction  and  Inward  Rotation — The  Stage  of 
Apparent  Shortening. — If  the  disease  is  of  a  more  acute  type, 
and  if  locomotion  be  permitted,  the  attitude  usually  changes  to  one 
of  increased  flexion,  and  adduction  and  inward  rotation  replace  ab- 
duction and  outward  rotation.  This  attitude  is  an  indication  that  the 
part  is  so  disabled  as  to  be  of  little  use,  and  it  is  instinctively  drawn 


SYMPTOMS. 


231 


into  a  more  protected  attitude  where  it  may  be  used  as  little  as  pos- 
sible., sif  the  patient  be  confined  to  the  bed,  or  does  not  walk,  as  in 
hip  disease  in  infancy,  the  attitude  of  abduction  may  persist,  although 
the  muscular  spasm  may  be  intense.  Thus  it  would  appear  that 
locomotion  has  a  distinct  influence  on  the  character  of  the  distortion. 


Fig.  163. 


Fig.  164. 


The  stage  of  appurent  shortening.     When 
the  adducted  limb  is  placed  iu  the  line  of  the 
The  stage  of  apparent  shortening.    The  adduc-    body,  the  pelvis  is  tilted  upward  to  a  corres- 
tion  of  the  right  thigh  is  made  evident  by  the  in-    ponding  degree  on  the  adducted  side  and  down- 
voluntary  crossing  of  the  legs  when   the   anterior     ward  on  the  other.  ^    i  /-      x, 
superior  spines  arl  on  the  same  plane.                                   The  patient  has  compensated  for  the  appar- 
^            *^                                                                           ent  shortening  by  flexing  the  knee  on  the  sound 

side.    This  does  not  appear  in  the  photograph. 


Flexion,  adduction  and  inward  rotation  cause  apparent  or  practical 
shortening  ;  for  in  order  to  bring  the  adducted  limb  to  the  middle  line 
of  the  body  and  parallel  with  its  fellow,  the  pelvis  must  be  tilted  up- 
Avard  on  the  affected  side  and  downward  on  the  other,  the  lumbar 
spine  bending  with  a  convexity  toward  the  lower  side,     (Figs.  164, 


232 


TUBERCULOUS  DISEASE  OF  THE  HIP  JOINT. 


Fig.  165. 


167.)  If  the  level  of  the  pelvis  be  restored,  the  adducted  limb  will  be 
crossed  over  its  fellow,  and  the  deformity  is  made  evident.  (Fig.  163.) 
As  has  been  stated  the  attitude  of  flexion,  adduction  and  inward 
rotation,  if  it  appears  early  in  the  disease,  is  usually  an  indication  of 
acute  and  disabling  pain  and  of  corresponding  intensity  of  muscular 
spasm.  But  in  most  instances  it  is  associated  with  the  later  and  de- 
structive stage  of  the  disease  and  it  by  no 
means  indicates  that  the  preceding  symptoms 
have  been  more  than  ordinarily  acute.  In  fact 
it  is  the  attitude  characteristic  of  a  so-called 
"  natural  cure  "  (Fig.  165)  when  mechanical 
treatment  has  not  been  employed.  It  more 
often  accompanies  the  later  stage  of  the  dis- 
ease, because  its  causes  are  in  great  degree 
mechanical. 

The  mechanics  of  the  distortion  will  be 
made  clearer  if  it  be  compared  to  the  defor- 
mity symptomatic  of  dorsal  dislocation  of  the 
hip.  In  this  displacement  the  femur,  forced 
upward  and  backward  upon  the  pelvis,  is  fixed 
in  an  attitude  of  extreme  flexion,  adduction 
and  inward  rotation.  Each  of  the  destructive 
changes  of  hip  disease,  the  enlargement  of 
the  acetabulum,  the  depression  of  the  neck 
of  the  femur,  the  erosion  of  the  head  of  the 
bone,  allows  an  elevation  of  the  femur  upon 
the  pelvis  or  an  approximation  to  a  dorsal  dis- 
placement. (Fig.  169.)  If  this  displacement 
occur  suddenly,  as  in  certain  cases  of  acute 
disease  attended  by  effusion  and  rupture  of 
the  capsule,  the  limb  immediately  assumes  an 
attitude  typical  of  dorsal  dislocation  ;  but  in 
the  ordinary  form  of  disease  the  changes  are 
very  gradual,  the  pelvis  and  the  femur,  being 
in  most  instances  undeveloped,  more  easily 
accommodate  themselves  to  the  changed  con- 
ditions so  that  the  actual  distortion  is  less 
marked  than  in  a  similar  subluxation  of 
traumatic  origin  in  the  adult,  but  the  simile 
will  serve  to  illustrate  the  mechanical  causes 
of  distortion,  and  why  such  deformity  may 
recur  after  correction,  even  though  the  disease  has  entirely  disappeared.  . 

Outward  rotation  of  the  limb  is  usually  associated  with  abduction, 
and  inward  rotation  with  adduction,  but  in  certain  instances  outward 
rotation  may  be  combined  Avith  adduction  and  vice  versa.  These  ir- 
regular attitudes  are  more  often  observed  in  cases  that  have  received 
mechanical  or  operative  treatment. 

As  lias  been  stated,  the  distortions  of  the  early  stage  of  hip  disease 


The  final  effect  of  hip  disease 
when  untreated.  The  natural 
cure,  with  flexion  and  adduc- 
tion. 


SYMPTOMS. 


233 


are  caused  almost  entirely  by  muscular  contraction  which  relaxes  under 
the  influence  of  an  anaesthetic,  but  after  a  time  the  attitude  is  still 
further  assured  by  accommodative  changes  in  the  muscles  and  fascia 
and  by  contractions  and  adhesions  about  the  capsule.    Thus  an  attitude 
which  was  originally  a  symptom  may  persist  after  the  cure  of  the  disease. 


Fig.  166. 


Fig.  167. 


Untreated  hip  disease.  Flexion  de- 
formity to  nearly  a  right  angle  with 
the  body.  Trochanter  two  inches 
above  Nelaton's  line.  Compensatory 
lordosis. 


Stage  of  apparent  shortening.  The  left  limb  is 
adducted  35°,  making  an  apparent  shortening  mea- 
sured from  the  umbilicus  of  more  than  two  inches. 
In  order  to  reduce  the  obliquity  of  the  pelvis,  the 
adducted  leg  must  be  crossed  over  its  fellow.  (See 
Fig.  163. )  The  apparent  shortening  is  compensated 
by  the  flexion  at  the  knee  on  the  sound  side.  This 
is  not  made  clear  in  the  photograph. 


In  conclusion  it  may  be  stated  that  flexion  is  practically  an  invari- 
able symptom  in  hip  disease  because  complete  extension,  the  attitude 
that  puts  most  strain  upon  the  joint,  is  first  restricted.  Flexion  is,  in 
the  milder  or  in  the  earlier  class  of  cases,  usually  combined  with  ab- 
duction and  outward  rotation,  the  attitude  of  inactivity.     Increased 


234  TUBERCULOUS  DISEASE  OF  THE  HIP  JOINT. 

ilexioD,  accompanied  by  adductioD  and  inward  rotation  in  the  early 
stage,  is  an  indication  of  a  more  acute  phase  of  the  disease,  but  if  the 
attitude  is  retained  for  a  time  it  becomes  fixed  by  accommodative 
changes  in  the  tissues  so  that  this  distortion  is  not  unusual  in  cases  in 
which  the  damage  to  the  joint  may  be  very  slight,  as  for  example, 
when  it  follows  rheumatism  or  some  form  of  infectious  arthritis.  But  in 
most  instances  the  attitude  is  indicative  of  more  advanced  disease  and 
of  serious  changes  within  the  joint. 

Changes  in.  the  Contour  of  the  Hip. — In  the  early  stage  of  the 
disease  the  changes  in  contour  are  caused  in  great  part  by  the  attitude 
of  the  limb.  If,  as  is  usual,  it  is  flexed,  abducted  and  rotated  outward, 
the  buttock  appears  somewhat  flatter  and  broader  than  its  fellow.  The 
gluteo-femoral  fold  is  lower  because  of  the  tilting  downward  of  the 
pelvis  and  it  is  shallower  because  of  the  flexion.  If  the  thigh  is  ad- 
ducted,  the  gluteal  fold  will  be  elevated  and  shortened.  On  the 
anterior  aspect,  the  iuguino-femoral  fold  is  deepened  and  lengthened 
by  flexion  and  adduction,  while  abduction  makes  it  less  noticeable. 
Hoifman  has  called  attention  to  the  fact  that  the  genitals  and  the  inter- 
gluteal  fold  point  toward  the  adducted  and  away  from  the  abducted 
thigh.  Adduction  makes  the  trochanter  more  prominent,  and  abduc- 
tion makes  it  less  prominent. 

To  these  primary  changes  in  the  appearances  must  be  added  the 
effect  of  atrophy  or  of  infiltration  and  swelling,  due  directly  to  the  dis- 
ease. A  certain  amount  of  swelling  is  often  apparent  in  the  inguino- 
femoral region,  and  infiltration  of  the  deeper  tissues  is  sometimes 
evident  on  palpation.  In  such  cases  there  is  usually  a  certain  sensitive- 
ness to  deep  pressure,  behind  or  in  front  of  the  trochanter.  Palpable 
or  evident  abscess  is  unusual  in  the  early  stage  of  the  disease. 

Atrophy. — Atrophy  is  an  important  sign  of  joint  disease.  It  is 
often  appreciable  to  the  eye  and  to  the  hand,  and  it  is  always  demon- 
strable by  measurement.  It  is  an  important  symptom  because,  if  well 
marked,  it  shows  that  the  disease  must  have  existed  for  some  time, 
whatever  may  be  the  statement  of  the  patient's  relatives. 

The  atrophy  affects  the  muscles  of  the  entire  limb,  although  it  is 
somewhat  more  marked  in  the  muscles  of  the  thigh  than  in  the  calf. 
In  the  ordinary  case  of  hip  disease  in  childhood,  when  the  patient  is 
first  brought  for  treatment,  it  averages  from  one  half  to  one  inch  in 
the  thigh  and  somewhat  less  in  thecal^     , 

The  Causes  of  Atrophy. — The  causes  of  the  atrophy  secondary 
to  joint  disease  have  been  the  subject  of  much  discussion.  As  it  is 
associated  with  an  increase  of  the  reflex  excitability  of  the  muscles, 
and  as  it  often  progresses  with  great  rapidity,  the  prevailing  theory  has 
been  that  of  Vulpian  and  Charcot,  that  it  is  of  nervous  or  reflex  origin. 
According  to  this  hypothesis  the  atrophy  is  the  result  of  a  change  in 
the  trophic  centers  of  the  spinal  cord,  ''  an  inertia,"  due  to  irritation  of 
the  articular  filaments  of  the  nerves. 

Another  theory  has  been  advanced  by  Saborin.  As  branches  of  the 
same  nerves  are  distributed  to  the  joint  and  to  the  surrounding  mus- 


SYMPTOMS.  235 

cles,  he  suggests  that  the  atrophy  may  be  caused  by  a  direct  implica- 
tion of  the  nerves  whose  filaments  are  involved  in  the  disease  of  the 
joint,  a  form  of  molecular  neuritis. 

Admitting  that  the  secondary  causes  of  atrophy  are  somewhat 
obscure,  one  cause,  and  by  far  the  most  important,  is  very  evident. 
This  is  physiological  disuse,  and  thus  diminished  nutrition  of  the 
limb  which  has  become  incompetent  to  carry  out  its  full  function. 
Atrophy  is  a  constant  symptom  of  simple  disuse  in  the  absence  of  dis- 
ease. If  a  bone  has  been  broken,  atrophy  of  the  surrounding  muscles 
is  observed.  If  anchylosis  of  a  joint  occur  from  any  cause,  whether 
it  be  from  injury  or  disease,  atrophy  of  the  muscles,  whose  function 
has  been  abolished,  follows.  Even  the  atrophy  caused  by  disease  of 
the  hip  joint  is  greater  when  the  limb  has  been  fixed  in  apparatus, 
than  when  none  has  been  applied,  although  the  treatment  has  allayed 
the  pain  and  has  checked  the  progress  of  the  disease.  This  point  is 
illustrated  by  the  observations  of  Brackett  ^  who  contrasted  the  atrophy 
of  hip  disease  in  two  groups  of  patients,  in  one  of  which  motion  had 
been  permitted,  while  in  the  other  fixation,  as  complete  as  possible, 
had  been  employed.  In  the  first  group  the  average  of  atrophy  was  but 
1  per  cent,  of  the  volume  of  the  thigh  and  .89  per  cent,  of  that  of  the 
leg,  as  contrasted  with  23  per  cent,  and  17  per  cent,  in  the  second 
class. 

It  has  been  stated  in  objection  to  this  theory  that  atrophy  is  observed 
even  though  the  patient  be  confined  to  the  bed,  but  under  these 
conditions  there  would  be  relative  disuse  of  a  limb  if  motion  caused 
pain  or  discomfort.  Meanwhile  a  lesser  atrophy  might  be  demonstrated 
in  the  sound  limb  that  had  been  deprived  of  its  normal  stimulus,  just 
as  relative  hypertrophy  of  a  limb  which  has  to  perform  double  func- 
tion, is  often  observed. 

The  atrophy  caused  by  physiological  disuse  and  diminished  nutrition 
affects  all  the  components  of  the  limb.  The  skin  becomes  thinner,  the 
muscles  lose  in  volume,  the  contractile  substance  is  replaced  in  part  by 
fat  and  by  fibrous  tissue,  and  the  medullary  canals  of  the  bones  enlarge 
at  the  expense  of  the  cortical  substance. 

In  childhood,  the  period  of  rapid  development,  disuse  often  causes 
a  retardation  in  growth  of  the  entire  extremity.  This  may  be  apparent 
in  the  foot  when  it  is  placed  by  the  side  of  its  fellow,  while  the  dimin- 
ished growth  in  length  of  the  limb,  may  be  demonstrated  by  measure- 
ment. Brackett,  in  a  series  of  cases,  found  this  shortening  to  be  dis- 
tributed as  follows  :  average  loss  of  the  femur,  Q.()  per  cent,  and  of 
the  tibia  5.4  per  cent,  of  the  normal  length. 

This  atrophy,  the  direct  result  of  the  disease  and  of  the  long  con- 
tinued disuse  during  the  period  of  repair,  becomes  less  noticeable  after 
function  is  resumed.  The  degree  of  final  inequality  depending  upon 
the  severity  of  the  disease,  the  duration  of  the  treatment  and  upon  the 
impairment  of  function.  But  even  when  free  motion  in  the  joint  is 
retained,  a  certain  amount  of  atrophy  always  persists  and  the  loss  in 
1  Trans.  Am.  Orth.  Ass'n,  Vol.  IV. 


236 


TUBERCULOUS  DISEASE  OF  THE  HIP  JOINT. 


growth  is  never  replaced.  If  motion  is  completely  abolished  the  muscles 
about  the  joint  lose  in  bulk  in  proportion  to  the  disuse  of  their  normal 
function  ;  whereas  the  bones  of  the  limb  which  are  still  used  to  sup- 
port the  weight  retain  to  a  greater  degree  their  normal  size  and  length. 
Combined  with  the  atrophy  of  the  weak  limb  there  is  a  relative  hyper- 
trophy of  the  sound  leg  which  is  forced  to  assume  more  than  its  share 
of  work. 

Actual  Shortexixg. — Actual  shortening  of  the  limb  is  a  common 

Fig.  168. 


Early  stage  of  disease  of  the  left  hip  joiut  (to  the  right  in  the  picture)  of  the  synovial  type,  show- 
ing irregularity  iu  the  shape  of  the  acetabulum. 


eifect  of  hij)  disease,  but  it  can  hardly  be  called  a  symptom  for  it  is  not 
present  in  the  early  stage  of  the  disease. 

The  causes  of  actual  shortening  may  be  classified  as  : 

1.  Disuse  of  the  limb. 

2.  The  effect  of  the  di.sease  upon  the  epiphysis  of  the  head  of  the  femur. 


SYMPTOMS.  237 

3.  The  more  general  destructive  effects  of  the  disease  that  cause  up- 
ward displacement  of  the  femur. 
(a)  Erosion  of  the  head. 
(6)  Erosion  of  the  acetabulum. 
(c)   Depression  of  the  neck  of  the  femur. 
Disuse,  throughout  a  long  period  of  treatment,  may  cause  a  certain 
amount  of  shortening  of  the  entire  limb.     To  this  the  shortening  of  the 

Fig.  169. 


Advanced  disease  showing  wandering  of  the  aeetabuhim  and  the  obliquity  of  the  pelvis  due  to  ad- 
duction.    Actual  shortening  1  inch,  apparent  shortening  3  inches. 

bones  of  the  leg  and  of  the  foot  may  be  attributed  in  great  part.  If 
the  epiphysis  of  the  head  of  the  femur  is  destroyed  in  whole  or  in  part 
or  if  the  disease  hastens  its  union  with  the  bone,  a  certain  loss  of  growth 
must  follow.  This  is  of  course  slight  in  degree  because  this  epiphysis 
is  relatively  unimportant  compared  with  that  at  the  lower  extremity  of 
the  bone.  From  these  two  causes,  the  atrophy  of  disuse  and  the  effect 
of  the  disease  upon  the  epiphysis,  relative  shortening  of  the  limb  may 
increase  after  the  disease  is  cured. 


238 


TUBERCULOUS  DISEASE  OF  THE  HIP  JOINT 


Erosion  of  the  head  of  the  femur  and  of  the  upper  border  of  the  acetab- 
ulum are  usually  combined  in  those  cases  in  which  the  shortening  is  in 
part  dependent  on  upward  displacement  of  the  trochanter.  (Fig.  156.) 
Depression  of  the  neck  of  the  femur  to  an  appreciable  degree  is  less 
common.  Elevation  of  the  trochanter,  due  to  one  or  more  of  these 
causes,  a  form  of  subluxation,  is  very  common,  particularly  so  in  those 
cases  in  which  the  protective  treatment  has  been  inefficient.  Greater 
displacement  follows  fracture  of  the  weakened  neck  and  complete  ab- 
sorption of  the  head,  and  occasionally  a  fairly  normal  femur  may  be 
actually  dislocated  as  a  result  of  sudden  eifusion  into  the  joint  with 
rupture  of  the  capsule,  a  form  of  pathological  dislocation. 

Actual  Lexgthexixg  of  the  limb  as  the  result  of  disease  is  occa- 
sionally observed,  caused  it  may  be  inferred,  by  stimulation  of  the 
growth  of  the  epiphysis  of  the  head;  but  the  most  extreme  instances 
are  those  in  which  the  upper  portion  of  the  shaft  of  the  femur  is  in- 
volved, the  lengthening  being  the  effect  of  an  irritative  hypertrophy. 

Retard ATiox  of  Growth. — As  has  been  stated,  all  the  components 
of  the  limb  are  affected  by  the  retardation  of  the  growth.  Brackett's 
observations  on  this  point  have  been  mentioned,  and  the  following  table, 
showing  the  relative  measures  of  the  bones  in  cases  under  treatment 
by  D5llinger^  of  Budapesth,  presents  the  subject  in  a  convenient  form  : 


No. 
of  case. 

Age  at  inception. 

Duration 
of  disease. 

Length 
of  femur  in  cm. 

Diffe- 

Length 
in  tibia  in  cm. 

Diflfe- 

Years. 

Months. 

Years. 

Months. 

Diseased.;  Normal. 

Diseased.    Normal. 

1 

8 

6 



6 

28^ 

28 

+J 

24 

24 

— 

2 

3 

4 

— 

8 

23 

24 

1 

19 

19 

— 

3 

2 

10 

1 

8 

24 

24 

— 

19.5 

19.5 

— 

4 

5 



2 

— 

29       i      30 

1 

23.5 

23.5 

— 

5 

6 

— 

2 

— 

27            28 

1 

23 

23 

— 

6 

7 

— 

2 

— 

32            33 

1 

27 

27 

— 

7 

9 



2 

— 

37            37 

— 

30 

30 

— 

8 

1 



4 

— 

22             24 

2 

18.5 

19 

0.5 

9 

13 

— 

4 

— 

38       i      41 

3 

34 

34 

— 

10 

4 

6 

5 

— 

32 

34 

2 

27 

27 

— 

11 

— 

2^ 

6 

— 

26 

27 

1 

21 J 

23 

1 

12 

13 

7 

— 

38 

40 

2 

33 

33 

— 

13 

2 

— 

8 

— 

35 

36 

1 

28 

28 

— 

14 

6 



8 

— 

38 

38 

— 

31 

32 

— 

15 

11 

— 

8 

— 

40       i      44 

4 

34 

34 

— 

16 

5 

— 

10 

— 

45 

46 

1 

— 

— 

— 

17 

5 



11 

— 

41 

44 

3 

31 

37 

6 

18 

6 



14 

— 

44 

48 

4 

36 

39.5 

3.5 

19 

2 



18 

— 

36 

46 

10 

38 

38 

— 

20 

2 

— 

28 

— 

44|     !      45 

* 

37.5 

37.5 

— 

A  similar  investigation  of  thirty-three  cases  under  treatment  at  the 
Hospital  for  Ruptured  and  Crippled,  New  York,  has  been  made  re- 
cently by  Dr.  Henry  Ling  Taylor.  In  these  cases  the  shortening  of 
the  bones  was  found  to  be  more  generally  distributed  than  in  those  re- 
ported by  Dollinger,  as  is  illustrated  by  the  following  table  : 

'  Zeits.  fur  Orth.  Clilr.,  Bd.  1,  1892. 


SYMPTOMS. 


239 


Dura-  1 

Dura- 

Shortening in  i 

nches. 

Age. 

Side. 

tion  of 
disease, 

tion  of 
treatm., 

Ab- 
scess. 

Case.      ^ex. 

years. 

years. 

limb. 

]'  emur.    Tibia. 

Foot. 

Patella. 

1        F. 

3J 

L. 

1 

1 

No 

* 

-    :     ^ 

8" 

* 

2 

M. 

7 

K. 

li 

1 

No 

i 

X      ,      i- 

3 
8^ 

i 

3 

M. 

5 

L. 

2 

1 

No 

i 

i     ;     I 

i 

+ 

4 

M. 

5 

K. 

2 

H 

No 

f 

\     ,     f 

* 

i 

5 

M. 

U 

L. 

2.f 

H 

Yes 

3 

4 

\         1 

t 

i 

6 

F. 

U 

L. 

3 

3 

No 

—       — 

i 

7 

F. 

u 

E. 

3 

— 

No 

* 

— 

} 



8 

M. 

6 

E. 

3 

2^ 

No 

H 

i 

1 

* 

9 

F. 

13 

L. 

3^ 

2 

No 

I 

i 

1 

10 

F. 

7 

L. 

U 

3* 

No 

If 

i 

f 

7 
8" 

1 

4 

11 

M. 

7 

E. 

3* 

3^ 

Yes 

1 

i 

3. 

4 

f 

3 

g 

12 

F. 

11 

E. 

3^ 

H 

No 

1* 

i 

8 

i 

i 

13 

F. 

9 

L. 

3i 

3i 

No 

U 

* 

i 

i 

Average 

7 

2^ 

2 

i          -3- 
4 

i 

1 

i 

I 

14 

M. 

7 

E. 

4 

4 

No 

1 

3. 

4 

1 
4 

f 

1 

15 

F. 

8i 

E. 

4 

4 

No 

1 

i 

1 

5 

k 

t 

16 

F. 

12 

E. 

5 

4 

Yes 

Zk 

* 

u 

8 

X 

17 

F. 

11 

E. 

5* 

4 

Yes 

2^ 

1 

^ 

i 

^ 

18 

F. 

13 

L. 

6 

3 

No 

2 

+ 

u 

^ 

i 

19 

F. 

12 

L. 

6 

4 

No 

7 
8" 

3^ 

4 

4 

* 

20 

F. 

10 

L. 

6* 

4 

No 

u 

i 

i 

i 
4 

21 

M. 

14 

L. 

7 

X 

Yes 

2^ 

X 

* 

i 

22 

F. 

15 

E. 

7 

5 

No 

21 

X 

1 

* 

X 

23 

M. 

9J 

E. 

7 

i 

Yes 

H 

— 

i 

i 

X 

Average 

11 

5^ 

^ 

If 

J 

1 

J 

3 

8 

24 

F. 

13 

E. 

8 

7 

Yes 

2} 

i 

u 

1 

1 

4 

25 

M. 

15 

E. 

9 

6 

Yes 

4* 

2 

ll 

X 

X 

26 

M. 

lOJ 

E. 

9 

X 

No' 

1* 

* 

i 

i 

^ 

27 

F. 

18 

E. 

9 

7 

No 

2* 

X 

1 

^ 

i 

28 

M. 

18 

E. 

11 

10 

Yes 

2 

* 

1 

* 

X 

29 

F. 

15 

L. 

11 

7 

Yes 

3 

1 

4 

* 

i 

* 

30 

F. 

15 

E. 

11 

5 

Yes 

1 

1 
4 

1 

4 

* 

1 

31 

F. 

15 

E. 

lU 

9^ 

Yes 

3 

4 

3 

4 

* 

k 

32 

F. 

16 

L. 

14 

1 

No 

U 

f 

f 

* 

+ 

33 

F. 

21 

L. 

17 

6 

Yes 

5* 

2J 

2^ 

* 

i 

Average 

15 

11 

6 

2| 

7 
8" 

1 

* 

f 

—  Measurements  equal. 

X  Measurements  not  taken. 

Measurements  of  the  femur  from  the  apex  of  the  great  trochanter  to  the  knee  joint. 
Patella  measured  transversely.  The  cases  are  grouped  according  to  the  duration  of 
disease  and  the  averages  are  given  separately  for  each  group. 


Dr.  Taylor  measured  also  ten  cases  of  unilateral  poliomyelitis,  in 
patients  of  an  average  age  of  thirteen  years  with  an  average  duration 
of  disability  of  ten  years.  The  average  shortening  in  these  cases  was 
one  and  three-fourths  inches  and  in  no  case  was  it  greater  than  two 
and  one-half  inches.  It  will  be  noted  that  the  retardation  of  growth 
in  this  group  corresponds  closely  with  that  of  the  third  group  of  cases 
of  hip  disease^  in  which  the  disability  was  of  about  the  same  duration. 


240*  TUBERCULOUS  DISEASE  OF  THE  HIP  JOIST. 

Taylor  concludes  that  the  retardation  of  growth  from  unilateral  hip 
disease  in  childhood  is  dependent  in  great  degree  upon  the  duration 
of  the  disability  and  upon  the  corresponding  restraint  of  function. 
Similar  observations  on  fifty  cases  of  hip  disease  have  been  recorded  by 
Hibbs.^  In  eleven  of  these  cases  the  femur  was  found  to  be  slightly 
longer  on  the  diseased  side. 

General  Symptoms  of  the  Disease.  Debility. — If  the  disease  be 
sufficiently  painful  to  cause  loss  of  sleep,  and  to  affect  the  appetite, 
pallor  and  loss  of  flesh  and  strength  may  be  expected.  It  must  be 
borne  in  mind,  however,  that  the  patient  may  have  been  "  delicate  " 
long  before  the  local  tuberculous  disease  was  acquired.  At  all  events, 
from  the  diagnostic  standpoint  at  least,  the  local  disease  has  no  charac- 
teristic influence  upon  the  general  condition  and  the  appearance  of  per- 
fect health  is  not  at  all  unusual  among  patients  with  hip  disease. 

Fever. — It  is  probable  that  a  slight  elevation  of  temperature  might 
be  detected  in  a  large  proportion  of  the  patients,  and  in  such  cases 
actual  appreciable  fever  often  follows  over-exertion  or  injury.  Fever, 
as  a  symptom  of  infected  abscess  in  the  later  stage  of  the  disease,  is  of 
course  of  importance,  but  in  the  early  stages  of  the  disease  the  record 
of  the  temperature  would  be  of  but  little  diagnostic  value. 

The  History  and  the  Method  of  Examination. — In  considering 
the  differential  diagnosis  of  tuberculous  disease  of  the  hip  joint  one 
should  keep  its  characteristics  in  mind.  It  is  a  chronic  disease,  in 
that  the  symptoms  may  have  been  present  for  weeks  or  months  or 
even  years  before  the  patient  is  brought  for  treatment.  It  is  a  disease 
confined  to  a  single  joint,  thus  differing  from  rheumatism  and  similar 
affections  in  which  several  joints  are  involved.  It  does  not  get  well ; 
thus  it  may  be  differentiated  from  injury  and  from  the  minor  affections 
that  simulate  some  of  its  symptoms.  It  causes  a  limp.  It  is  accom- 
panied by  reflex  muscular  spasm,  usually  by  a  certain  amount  of  de- 
formity and  by  general  atrophy  of  the  muscles  of  the  limb. 

The  importance  of  the  inheritance  and  of  the  personal  history  of  the 
patient  has  already  been  mentioned  in  the  consideration  of  Pott's  dis- 
ease. In  recording  the  history  in  this,  as  in  all  other  chronic  diseases 
of  childhood,  one  attempts  to  ascertain  the  approximate  duration  of 
the  pathological  process  rather  than  the  duration  of  the  more  acute 
symptoms  for  which  the  patient  has  been  brought  for  treatment.  One 
asks,  therefore,  when  the  child  was  last  perfectly  well,  and,  bearing  in 
mind  the  remission  of  symptoms,  one  asks  if  limp  or  pain  had  been 
noticed  at  any  time  before  the  more  acute  symptoms.  In  the  history 
there  is  almost  invariably  mention  of  a  fall,  and  one  must  ascertain 
whether  the  fall  had  any  influence  in  the  causation  of  the  symptoms, 
remembering  that  the  weakness  and  interference  with  function  due  to 
joint  disease  more  often  cause  falls  than  falls  cause  joint  disease. 

Physical  Examination. — One  begins  the  physical  examination  by 
the  observation  of  the  general  condition  of  the  patient  and  notes  the 
attitudes  and  the  character  of  the  limp.     The  patient's  clothing  is  then 
IX.  Y.  Med.  Jour.,  Dec.  16,  1899. 


PHYSICAL  EXAMINATION.  241 

entirely  removed  and  one  may  observe  the  contour  of  the  part  and  the 
general  influence  of  the  affection  upon  the  mechanism  of  the  body. 
The  palient  is  then  placed  on  his  back  upon  a  table,  with  the  legs 
parallel  to  one  another,  so  that  their  relative  length  and  size  may 
be  observed.  If  the  pelvis  is  level,  when  the  limbs  are  parallel, 
there  can  be  no  persistent  abduction  or  adduction,  for  when  the  two 
anterior  superior  spines  are  on  the  same  plane,  such  distortion  is  al- 
ways evident.  If  the  lumbar  spine  and  the  popliteal  surfaces  of  the 
knees  rest  on  the  table  simultaneously,  it  shows  too  that  persistent  flex- 
ion is  absent.  One  next  tests  the  functions  of  the  hip  joints,  always 
beginning  with  the  sound  side  for  the  purpose  of  comparison  and  in 
order  that  the  patient  may  become  accustomed  to  the  manipulation,  be- 
fore the  one  suspected  of  disease  is  tested.  Muscular  spasm,  due  to 
disease  within  a  joint,  limits  motion  in  every  direction,  thus  differing 
from  various  conditions  outside  the  joint  that  may  limit  its  motion  in 
one  or  more,  but  not  in  all  directions. 

One  compares  the  flexion,  abduction,  adduction  and  rotation  of  the 
limbs  while  the  child  lies  upon  its  back ;  it  is  then  turned  upon  its 
face  to  test  for  extension,  by  holding  the  pelvis  flat  upon  the  table  with 
one  hand,  while  the  thigh  is  gently  elevated  with  the  other.  (Fig.  16.) 
The  normal  range  of  extension,  in  childhood,  is  at  least  ten  degrees 
backward  from  the  line  of  the  body,  and  limitation  of  this  range  is  the 
earliest  sign  of  approaching  deformity  of  hip  disease.  It  may  precede 
the  restriction  of  the  extremes  of  motion  in  other  directions,  although 
this  is  unusual,  and  if  this  motion  is  unrestricted,  disease  of  the  joint 
may  be,  practically  speaking,  excluded.  The  character  of  the  reflex 
spasm  that  limits  motion,  and  the  indications  of  discomfort  when  the 
limit  has  been  reached  have  been  described. 

Measurements. — The  measurements  of  the  limbs  are  then  made.  One 
first  ascertains  the  actual  length  of  the  limbs  by  measuring  from  the 
anterior  superior  spines  of  the  pelvis  to  the  extremities  of  the  internal 
malleoli,  actual  shortening  being  of  course  absent  in  the  early  stage  of 
the  disease.  The  second  measurement  is  from  the  umbilicus  to  show 
the  amount  of  apparent  shortening  or  lengthening  that  may  be  present 
if  the  limb  is  distorted.  The  actual  length  of  the  legs,  as  measured 
from  the  anterior  superior  spines,  is  not  changed  by  tilting  of  the  pel- 
vis, but  as  the  umbilicus  is  in  the  middle  line  of  the  body  above  the 
pelvis,  measurement  from  this  point  simply  shows  the  actual  distance 
to  the  malleoli.  Adduction  causes  an  obliquity  of  the  pelvis,  conse- 
quently the  malleolus  on  the  affected  side  is  drawn  upward  or  nearer 
to  the  umbilicus,  while  the  other  is  carried  downward  to  a  correspond- 
ing distance.  (Fig.  167.)  If,  then,  the  measurements  from  the  um- 
bilicus to  the  malleoli  do  not  correspond  relatively  with  those  from  the 
anterior  superior  spines,  when  the  limbs  are  parallel  and  in  the  median 
line,  it  shows  distortion  ;  adduction,  if  the  limb  is  relatively  shorter,  ab- 
duction, if  it  is  relatively  longer  than  is  shown  by  the  measurement 
from  the  anterior  superior  spine.  It  has  been  stated  that  the  measure- 
ment from  the  anterior  superior  spine  is  not  changed  by  distortion. 
16 


242 


TUBERCULOUS  DISEASE  OF  THE  HIP  JOIST. 


It  is,  however,  shortened  slightly  by  outward  rotation  and  more  appre- 
ciably by  abduction  and  also  by  flexion.  Flexion  on  one  side  causes  a 
tilting  forward  of  the  pelvis  that  aflPects  the  measurements  on  both  sides, 
thus  it  is  customary,  if  the  flexion  is  considerable,  to  raise  the  sound 
leg  to  the  line  of  its  fellow  in  making  the  comparative  measurements, 
stating  in  the  record  that  the  limbs  have  been  measured  at  the  angle 
of  the  deformity. 

Method  of  Estimating  the  Degree  of  Distortion  of  the 
Limb. — As  has  been  stated,  when  the  pelvis  is  level,  distortion  of  the 
limb  is  ajjparent,  and  the  degree  of  distortion  can  be  measured  by  the 
goniometer.  (Fig.  159.)  But  it  may  be  more  easily  ascertained  by 
"  Lovett's  table."  ^     This  method  is  described  bv  its  author  as  follows  : 


Table  I. 
Distance  Between  Anterior  Superior  Spines  in  Inches. 


1  3   3^  4   4J 

5 

5J 

6 

H 

7 

n 

8 

8§ 

9 

9J  10 

11  12  13 

tD 

•S 

i 

50  40  40  30 

3° 

2° 

2° 

2° 

2° 

2° 

90 

2° 

2° 

1°  1° 

1°  1°  1° 

-2 

3. 

4 

jlO   8   7   6 

5 

5 

4 

4 

4 

4 

4 

4 

4 

3   3 

3   3  2 

14  12  11  10 

8 

8 

/ 

7 

6 

6 

5 

5 

5 

4   4 

4   3  3 

< 


« 


1    I  19 

1; 

lil  25 


17    14    13     11     10 


9      8 


21     18     16     14    13    12    11     10 


6     6 


30 

25 

22 

19 

17 

15 

14 

13 

12 

12 

11 

10 

10 

9 

9 

8 

7  7 

36 

30 

26 

23 

20 

18 

17 

15 

14 

13 

13 

12 

11 

10 

10 

9 

8  8 

42 

35 

30 

26 

23 

21 

19 

18 

16 

15 

14 

14 

13 

12 

12 

10 

10  9 

" 

40 

34 

30 

26 

24 

21 

20 

19 

17 

16 

15 

14 

14 

13 

12 

11  10 

39 

34 

29 

27 

24 

22 

21 

19 

18 

17 

16 

15 

14 

13 

12  11 

2 

2^ 

3 
4 


"  To  measure  bv  this  method,  the  patient  is  made  to  lie  straight,  with 
the  legs  parallel.  Real  shortening  is  measured  with  the  ordinary  tape 
measure,  and  apparent  shortening  is  obtaiued  in  the  same  way.  It 
may  be  repeated  that  real  or  bony  shortening  is  measured  from  the 
anterior  superior  iliac  spines  to  each  malleolus,  and  that  practical 
shortening  is  found  bv  a  measurement  taken  from  the  umbilicus  to 
each  malleolus.  The  difference  in  inches  between  the  two  kinds  of 
shortening  is  seen  at  a  glance.  The  only  additional  measurement 
iR.  AV.  Lovett,  Boston  Med.  and  Surg.  Jour.,  March  8,  1888. 


38  32 

29 

27 

25 

23 

21 

20 

19 

18 

17 

16 

14 

13  12 

42  35 

32 

29 

27 

25 

23 

22 

21 

19 

18 

18 

16 

14  13 

39 

36 

32 

30 

27 

26 

25 

22 

21 

20 

19 

17 

15  14 



40 

35 

33 

30 

28 

26 

24 

23 

22 

21 

19 

17  16 



... 

38 

35 

32 

30 

28 

26 

25 

23 

22 

20 

18  17 

42 

38 

35 

32 

30 

28 

26 

25 

23 

21 

19  18 

METHOD    OF  ESTIMATING    THE  DEGREE   OF  DISTORTION.     243 

necessary  is  the  distance  between  the  anterior  superior  spines,  which  is 
taken  with  the  tape.  Turning  now  to  the  table,  if  the  line  which 
represents  the  amount  of  diiference  in  inches  between  the  real  and  ap- 
parent shortening  is  followed  until  it  intersects  the  line  which  repre- 
sents the  pelvic  breadth,  the  angle  of  deformity  will  be  found  in 
degrees,  where  they  meet.  If  the  practical  shortening  is  greater  than 
the  real  shortening,  the  diseased  leg  is  adducted  ;  if  less  than  real  short- 
ening, it  is  abducted.  Take  an  example :  Length  (from  anterior  superior 
spine)  of  right  leg,  23  ;  left  leg,  22J  ;  length  (from  umbilicus)  of  right 
leg,  25  ;  left  leg,  23  ;  real  shortening,  J  inch,  apparent  shortening 
2  inches  ;  difference  between  real  and  practical  shortening,  1  ^  inches ; 
pelvic  measurement,  7  inches.  If  we  follow  the  line  for  1^  inches 
until  it  intersects  the  line  for  pelvic  breadth  of  7  inches,  we  find  12° 
to  be  the  angular  deformity,  as  the  practical  shortening  is  greater  than 
the  real,  it  is  12°  of  adduction  of  the  left  leg.  If  apparent  lengthen- 
ing is  present  its  amount  should  be  added  to  the  amount  of  actual 
shortening." 

If  flexion  be  present  the  degree  may  be  ascertained  by  raising  the 
flexed  leg  until  the  lumbar  spine  touches  the  table,  when  the  angle 
formed  by  the  leg  with  the  body  may  be  measured  with  the  goniometer 
(Fig.  162),  or  its  degree  may  be  ascertained  by  Kingsley's  table. 

"  The  patient  lies  upon  a  table  flat  on  his  back  and  the  surgeon  flexes 
the  diseased  leg,  raising  it  by  the  foot  until  the  lumbar  vertebrae  touch 
the  table,  showing  that  the  pelvis  is  in  the  correct  position.  The  leg 
is  then  held  for  a  minute  at  that  angle,  the  knee  being  extended,  while 
the  surgeon  measures  off  two  feet  on  the  outside  of  the  leg  with  a  tape 

Fig.    170. 


A  li 

Kingsley's  method  of  estimatiDg  flexion. 


measure,  one  end  of  which  is  held  on  the  table  (so  that  the  tape  mea- 
sure follows  the  line  of  the  leg)  {AB).  From  this  point  on  the  leg  (B) 
where  the  two  feet  reaches  by  the  tape  measure  one  measures  perpen- 
dicularly to  the  table  {BC),  and  the  number  of  inches  in  the  line  BC 
can  be  read  as  degrees  of  flexion  of  the  thigh,  by  consulting  Table  II. 
For  instance,  if  the  distance  between  the  point  on  the  leg  and  the 
table  is  12|^  inches  it  represents  31°  of  flexion  deformity  of  the  thigh. 


24i 


TUBERCULOUS  DISEASE  OF  THE  HIP  JOINT 


Table  II.^ 


In. 

Deg. 

In. 

Deg. 

In. 

Deg. 

In. 

Deg. 

0.5 

1 

6.5 

16 

12.5 

31 

18.5 

50 

1.0 

2 

7.0 

17 

13.0 

33 

19.0 

52 

1.5 

3 

7.5 

19 

13.5 

34 

19.5 

54 

2.0 

4 

8.0 

20 

14.0 

36 

20.0 

56 

2.5 

6 

8.5 

21 

14.5 

37 

20.5 

58 

3.0 

7 

9.0 

22 

15.0 

39 

21.0 

60 

3.5 

9 

9.5 

24 

15.5 

40 

21.5 

63 

4.0 

10 

10.0 

25 

16.0 

42 

22.0 

67 

4.5 

11 

10.5 

27 

16.5 

43 

22.5 

70 

5.0 

12 

11.0 

28 

17.0 

45 

23.0 

75 

5.5 

14 

11.5 

29 

17.5 

47 

23.5 

80 

6.0 

15 

12.0 

30 

18.0 

48 

24.0 

90 

"  If  the  leg  is  so  short  that  it  is  impracticable  to  measure  off  twenty- 
four  inches,  one  can  measure  twelve  inches ;  ascertain  from  here  the 
distance  to  the  surface  on  which  the  patient  is  lying  in  a  perpendicular 
line  in  the  same  way,  then  doubling  this  distance  and  looking  in  the 
table  as  before  the  amount  of  flexion  is  found." 

Atrophy. — The  circumference  of  the  thighs,  the  knees  and  the  calves 
is  then  measured  at  corresponding  points,  to  test  for  atrophy  or  for 
other  irregularities  that  may  require  explanation.  The  atrophy  of 
joint  disease  affects  the  entire  limb,  and  is  an  unfailing  symptom  ex- 
cept in  the  earliest  stage  of  the  disease.  It  might  be  concealed  in  the 
thigh  by  a  deep  abscess,  but  it  would  still  appear  in  the  calf. 

Local  Signs  of  Disease. — The  hip  joint  is  so  concealed  by  the 
overlying  tissues  that  the  local  sensitiveness  and  swelling  which  usu- 
ally accompany  similar  disease  at  the  knee  and  ankle,  are  often  absent. 
Firm  pressure,  before  or  behind  the  trochanter,  or  over  the  head  of 
the  femur,  usually  causes  some  discomfort,  however.  In  many  instances 
a  peculiar  resistance  of  the  deeper  parts,  caused  by  infiltration  of  the 
tissues  that  cover  the  joint,  is  evident  on  palpation  ;  and  swelling 
about  the  joint  and  thigh,  caused  by  effusion  or  by  deep  abscess,  is  not 
unusual  when  patients  are  first  brought  for  treatment.  Sensitiveness 
of  the  skin,  and  local  elevation  of  the  temperature  may  be  present  if 
the  disease  is  acute,  particularly  if  an  abscess  is  on  the  point  of  break- 
ing through  the  skin. 

It  must  be  evident  that  the  diagnosis  of  tuberculous  disease  of  the 
hip,  except  perhaps  in  the  stage  of  inception,  is  in  most  instances  evi- 
dent on  a  systematic  examination,  such  as  has  been  outlined  ;  and  it  is 
probable  that  errors  are  due  rather  to  a  neglect  of  such  examination 
than  to  any  particular  obscurity  that  the  ordinary  case  may  offer. 

Diagnosis.  Local  Irritation. — Strains  of  the  muscles  of  the  thigh, 
enlarged  glands  in  the  groin,  irritation  or  disease  of  the  genitals  may, 
in  infancy  or  early  childhood,  cause  persistent  flexion  of  the  thigh  and 
pain  on  motion.  Simple  muscular  strains  quickly  recover,  while  the 
inflamed  glands,  and  other  causes  of  local  irritation,  are  usually  ap- 
parent on  inspection. 

'  G.  L.  Kingsley  :  Bost.  Med,  and  Surg.  Jour.,  July  5,  1888. 


DIAGNOSIS.  245 

"  G-rowing  Pains." — So-called  growing  pain  is  probably  due  in  many 
instaneelB  to  strain  of  the  muscles  or  to  injury  about  the  hip  ;  in  other 
cases  it  may  be  explained  by  rheumatism. 

Local  Injury. — It  would  appear  that  injury,  often  of  a  trivial  char- 
acter, may  cause  congestion  in  the  neighborhood  of  the  epiphyseal  car-^ 
tilage  of  the  head  of  the  femur  and  that  injury  of  this  character  in 
delicate  children  may  be  the  predisposing  cause  of  tuberculous  disease. 
Such  a  sensitive  condition  causes  a  limp,  pain  or  discomfort  on  over- 
use and  a  certain  amount  of  restriction  of  motion.  These  symptoms 
may  last  a  few  days  or  a  few  weeks ;  they  may  disappear  and  recur 
from  time  to  time  and  they  can  only  be  distinguished  from  those  of 
incipient  disease  by  continued  observation. 

Synovitis. — In  certain  cases  of  injury  synovial  effusion  may  be  pres- 
ent, although  this  is  unusual. 

In  the  cases  in  which  the  functional  disturbance  is  caused  by  local 
irritation  or  by  slight  strain  the  symptoms  are  of  sudden  onset  and  are 
evidently  of  trivial  importance,  but  if  there  is  any  doubt  as  to  the 
diagnosis,  the  hip  should  be  bandaged  and  the  patient  should  remain 
in  bed  or  at  rest,  until  the  complete  subsidence  of  the  symptoms  or 
their  persistence,  makes  the  diagnosis  clear. 

Anterior  Poliomyelitis. — Occasionally  anterior  poliomyelitis  may  be 
accompanied  by  pain  on  motion  in  the  affected  limb,  before  paralysis  is 
apparent ;  but  in  a  few  days,  at  most,  the  diagnosis  is  evident. 

Rheumatism. — Rheumatism  is  usually  of  sudden  onset.  It  is  al- 
most always  migratory  in  character  and  i{  is  accompanied  by  fever.  If  it 
were  confined  to  a  single  joint,  as  is  sometimes  the  case  in  young  chil- 
dren, and  if  the  history  were  obscure,  the  diagnosis  might  be  uncer- 
tain for  a  time.  In  such  cases  appropriate  remedies  should,  of  course, 
be  employed. 

Scurvy. — This  is  also  an  affection  whose  symptoms  are  general  in 
character.  It  is,  therefore,  more  likely  to  be  confounded  with  rheu- 
matism than  with  a  local  disease.  In  rare  instances  one  joint  only  ap- 
pears to  be  involved,  but  this  is,  as  a  rule,  the  knee  rather  than  the 
hip.  Pain  on  motion  of  the  limbs,  in  an  infant  artificially  fed,  always 
suggests  scurvy. 

Infectious  Arthritis. — Mild  forms  of  infectious  arthritis  may  follow 
scarlet  fever,  diphtheria,  pneumonia  and,  in  a  more  severe  and  de- 
structive form  of  typhoid  fever.  As  a  rule  however  several  joints  are 
involved  and  although  the  affection  might  be  mistaken  for  rheumatism 
it  could  hardly  be  confounded  with  local  tuberculous  disease. 

Acute  Epiphysitis. — Infectious  arthritis  or  epiphysitis  of  the  hip  joint 
is  not  uncommon  in  early  infancy.  It  is  of  sudden  onset,  accompanied 
by  high  fever  and  by  constitutional  disturbance.  These  symptoms  to- 
gether with  the  local  heat  and  swelling,  caused  by  the  rapid  formation 
of  pus,  show  the  character  of  the  affection  and  indicate  the  necessity 
for  prompt  surgical  intervention. 

Extra-articular  Disease. — Disease  in  the  neighborhood  of  the  joint, 
as  of  the  trochanter,  or  of  the  tuberosity  of  the  ischium,  may  cause  a 


246  TUBERCULOUS  DISEASE  OF  THE  RIP  JOINT. 

limp  and  pain,  but  in  most  instances  the  local  sensitiveness  and  local 
swelling  indicate  the  seat  of  the  disease,  while  motion  of  the  joint  is 
limited  only  in  the  directions  that  cause  tension  on  the  sensitive  parts. 

Chronic  Eheumatoid  Arthritis.  Osteo-arthritis  of  the  Hip. — Rheuma- 
toid arthritis,  when  confined  to  the  hip  joint,  may  be  mistaken  for 
tuberculous  disease  and  at  times  the  diagnosis  may  be  obscure.  This 
is,  however,  a  disease  cf  adult  life  and  it  is  in  most  instances  accom- 
panied by  other  evidences  of  a  general  affection. 

Pott's  Disease. — Disease  of  the  lumbar  region  of  the  spine  before  the 
stage  of  deformity,  when  the  pain  is  referred  to  the  lower  extremities, 
and  in  which  unilateral  psoas  contraction  causes  a  limp,  is  almost  al- 
ways mistaken  for  hip  disease  although  the  distinction  between  them 
is  very  clear.  Psoas  contraction  limits  only  extension  ;  all  the  other 
movements  of  the  limb  are  free  and  unrestrained.  The  muscular 
spasm,  of  which  the  psoas  contraction  is  a  part,  is  a  spasm  of  the 
muscles  of  the  spine  about  the  seat  of  disease,  as  is  evident  on  exami- 
nation. Other  causes  of  psoas  contraction  have  been  mentioned  in  the 
consideration  of  Pott's  disease.  In  exceptional  cases  active  disease  of 
the  lower  region  of  the  spine  in  young  children  may  set  up  spasm  of 
the  muscles  about  the  hip,  and  vice  versa,  so  that  it  may  be  impossible 
to  decide  at  the  first  examination  whether  the  irritation  is  in  the  hip  or 
in  the  spine  or  in  both. 

Sacro-iliac  Disease. — Disease  of  the  sacro-iliac  junction  is  very  un- 
common in  childhood.  The  symptoms  and  the  attitude  resemble 
sciatica  rather  than  hip  disease.  There  is  local  pain  at  the  seat  of  dis- 
ease upon  lateral  pressure  on  the  pelvis,  and  if  the  pelvis  be  fixed,  the 
motion  at  the  hip  joint  will  be  found  to  be  free  and  painless. 

Disease  of  the  Bursse  about  the  Joint. — Inflammation  of  the  bursas 
about  the  hip  may  cause  local  swelling  and  sensitiveness,  a  limp  and 
limitation  of  motion  in  certain  directions,  but  the  characteristic  mus- 
cular spasm  of  hip  disease  is  absent.  Ilio-psoas  bursitis  forms  a  fluc- 
tuating swelling  on  the  inner  aspect  of  the  thigh,  gluteal  bursitis,  a 
localized  swelling  of  the  buttock. 

Coxa  Vara. — Coxa  vara,  or  depression  of  the  neck  of  the  femur,  is  a 
simple  deformity  in  which  disease  is  absent.  It  causes  a  limp  and  more 
or  less  discomfort,  but  the  character  of  the  deformity,  shown  by  the  actual 
shortening  and  by  the  elevation  and  prominence  of  the  trochanter  dis- 
tinguishes it  from  hip  disease  in  which  these  are  late  symptoms.  In 
coxa  vara  there  is  unequal  limitation  of  motion,  abduction,  flexion  and 
inward  rotation  being  somewhat  restricted  while  extension,  the  first 
motion  limited  in  hip  disease,  may  be  even  increased  in  range. 

Fracture  of  the  Neck  of  the  Femur  in  Childhood  or  Traumatic  Coxa 
Vara. — Fracture  of  the  neck  of  the  femur  in  childhood  is  often  of 
what  may  be  termed  the  green-stick  variety,  a  depression  of  the  neck 
of  the  femur  without  actual  separation  of  the  fragments  ;  and  in  many 
instances  the  patients  are  able  to  walk  about  within  a  short  time  after 
the  accident.  In  such  cases  the  limp  and  discomfort,  attended  during 
the  stage  of  repair  by  a  certain  degree  of  muscular  spasm,  are  often 


THE  RECORD.  247 

mistaken  for  the  symptoms  of  disease.  The  history  of  the  accident 
followed  by  immediate  disability ;  the  shortening  and  the  elevation  of 
the  trochanter,  should  establish  the  diagnosis. 

Congenital  Dislocation  of  the  Hip. — Congenital  dislocation  of  the  hip 
causes  a  limp,  but  it  is  a  limp  that  has  existed  since  the  child  began  to 
walk  and  that  is  unaccompanied  by  the  symptoms  of  disease.  The 
nature  of  the  disability  should  be  apparent  on  examination. 

Hysterical  Joint. — In  hysterical  subjects  a  limp,  apparent  pain  and 
distortion  of  the  limb,  often  following  slight  injury,  may  simulate  disease. 

Hysteria  is  very  uncommon  at  the  period  of  life  in  which  tubercu- 
lous disease  is  most  frequent.  Patients  suffering  from  hysterical  joints 
usually  present  other  symptoms  of  hysteria  ;  the  characteristic  signs  of 
disease,  muscular  spasm  and  atrophy,  are  absent ;  while  the  apparent 
discomfort  and  the  voluntary  distortion  are  quite  out  of  proportion  to 
the  physical  evidences  of  injury. 

The  X-Ray  in  Diagnosis. — Roentgen  pictures  are  of  far  more  value 
in  demonstrating  deformity  than  in  establishing  early  diagnosis  of  dis- 
ease, especially  at  the  hip  in  early  childhood,  when  so  large  a  part  of 
the  extremity  of  the  femur  is  cartilaginous.  The  pictures  are  of  value, 
however,  in  showing  the  destructive  effect  of  the  disease  on  the  head 
of  the  femur  or  acetabulum,  and  thus  giving  one  a  clearer  conception 
of  the  actual  condition  of  the  joint  than  would  be  possible  otherwise. 
(Fig.  1 68.)  In  older  subjects  it  might  be  possible  to  demonstrate  the 
presence  of  disease  in  the  interior  of  the  bone  by  this  means,  but  in 
any  event  Roentgen  pictures  are  of  value  only  when  interpreted  by 
knowledge  of  the  physical  signs. 

Method  of  Recording  a  Case. — The  record  should  contain  the 
general  history  of  the  patient  together  with  an  account  of  the  more  im- 
portant symptoms,  and  of  the  treatment  that  may  have  been  employed. 
The  physical  examination  should  include  the  weight  and  height,  for 
comparison  with  the  normal  standard,  and  as  a  basis  on  which  to  judge 
the  future  progress  of  the  case.  Then  follows  a  brief  description  of 
the  gait  and  attitude ;  of  the  character  of  the  distortion,  if  it  be  pres- 
ent, and  of  the  changes  from  the  normal  contour.  If  restriction  of 
motion  be  present,  its  causes  are  stated  if  possible ;  whether,  for  ex- 
ample, it  is  due  to  simple  muscular  spasm,  or  in  part  to  adhesions  and 
contractions.  The  presence  or  absence  of  heat  and  swelling,  of  ab- 
scesses, sinuses  and  the  like,  is  indicated.  If  there  is  actual  shorten- 
ing of  the  limb  its  causes  and  distribution  should  be  stated  ;  whether 
it  is  the  result  of  simple  retardation  of  growth  or  of  elevation  of  the 
trochanter,  as  may  be  ascertained  by  N6laton's  line  and  by  Bryant's 
triangle.  If  the  elevation  is  due  in  great  part  to  the  enlargement  of 
the  acetabulum,  while  the  upper  extremity  of  the  femur  remains  fairly 
normal  in  shape,  the  projection  of  the  trochanter  is  more  noticeable, 
and  the  distortion  of  the  limb  in  adduction  is  greater,  than  when  the 
elevation  is  the  result  of  destruction  of  the  head  of  the  bone.  In  this 
class  of  cases  Roentgen  pictures  are  of  service  in  showing  the  actual 
condition  of  the  joint.     (Fig-  169.) 


248  TUBERCULOUS  DISEASE  OF  THE  HIP  JOINT. 

A  condensed  account  of  the  more  important  points  in  the  physical 
examination  may  be  presented  by  the  formula  used  at  the  Hospital  for 
Ruptured  and  Crippled,  as  follows  :  R.A.— R.U.— R.T.— R.K.— R.C. 
— A.G.E.— A.G.F.— A.S.P.— L.A.— L.U.— L.T.— L.K.— L.C. 

"A"  indicates  the  distance  from  the  anterior  superior  spines  to  the 
internal  malleoli. 

"  U/'  from  the  umbilicus  to  the  same  points. 

u  T,"  "  K  "  and  "  C/'  the  circumferences  of  the  limb  at  the  thighs, 
knees  and  calves. 

"A.G.E."  indicates  the  angle  of  greatest  extension. 

"A.G.F.,"  the  angle  of  greatest  flexion.  Thus  the  restriction  of 
the  range  of  antero-posterior  motion  at  the  hip  is  shown  by  these 
measurements. 

"  A.S.P."  is  the  transverse  diameter  of  the  pelvis  between  the  ante- 
rior superior  spines,  the  measurement  required  in  Lovett's  table  for 
ascertaining  the  degree  of  lateral  distortion. 

If,  for  example,  the  record  read  : 

R.A.  18^— R.U.  20  — R.T.  11  — R.K.  8|— R.C.  7f— A.G.E.  150— A.S.P.  7 
L.A.  18J— L.U.  211— L.T.  10^— L.K.  8^- L.C.  71— A.G.F.   90 

it  would  show  at  a  glance  that  there  was  no  real  shortening,  that  the 
leg  was  abducted  because  there  was  one  and  a-quarter  inches  of  apparent 
lengthening,  according  to  the  table,  the  equivalent  of  ten  degrees  of  ab- 
duction. It  would  show  that  there  was  permanent  flexion  of  thirty  de- 
grees and  a  range  of  motion  between  the  limits  of  flexion  and  extension 
of  sixty  degrees,  as  compared  with  the  normal  of  about  1 30  degrees. 

The  following  details  from  the  one  thousand  cases  of  hip  disease  in- 
vestigated for  me  by  Dr.  D.  D.  Ashley  are  of  interest  as  illustrating 
the  character  of  the  cases  treated  at  the  Hospital  for  Ruptured  and 
Crippled. 

The  Duration  of  Disease  when  Treatment  was  Begun. 

Three  months  or  less 396     Four  years 21 

Three  to  six  month? 170     Five  years 17 

Six  months  to  one  year 80     From  five  to  ten  years 35 

One  year 124     From  ten  to  forty  year;^ 16 

Twoyears 75     Not  stated 37 

Three  years 29  I^OOO 

The  Degree  of  Deformity  Present  on  First   Examination. 

No  deformity 130  55  degrees  of  flexion 10 

5  degrees  of  flexion ;...     44  60       "         "         "     26 

10     "        "        "     89  65       "         "         "     8 

15     "         "        "     69  70       "         "         "     22 

20     "■         "        "     118  75       "         "         "     2 

25     ''         "        "     32  80      "         "         "     11 

30     "         "        "     135  85      "         "         "     1 

35     "         "        "     56  90       "         "         "     12 

40     "         "        "     70  More  than  90 1 

45     "         "        "     41  Not  stated 55 

50     "         "        ''     68  1,000 


TREATMENT. 


249 


Restriction  of  Motion  at  First  Examination. 

Normal  motion 30 

A  range  of  motion  through  105  degrees 14 


90 
75 
60 
45 
30 
15 
5 


65 
49 
95 
67 

112 
95 

157 


No  motion 147 

Not  stated 169 


1,000 

Attitude  of  the  Limb  at  First  Examination. 

Flexion  to  a  greater  or  less  degree 814 

No  flexion 130 

Not  stated 56 

1,000 

Other  Distortions  Recorded. 

Abduction 254 

Adduction 167 

External  rotation 166 

Internal  rotation 58 


Actual  Shortening  when  Treatment  was  Begun. 

\  inch 129     2^  inches 5 

i     "    143     2| 


f      "     22 

1  "     51 

IJinches 9 

li       "     16 

If       "     6 

2  "     21 


93 

3 

3J 
9h 


.      2 

.      2 

2 

2 

.      1 

416 


Shortening  absent  or  not  stated  in  584. 
Abscess  was  present  in  105  cases. 

Treatment. — The  principles  that  should  govern  the  treatment  of  a 
disease  are  best  indicated  by  the  study  of  cases  that  have  received  no 
treatment,  and  that  show  therefore  the  natural  history  of  the  affection. 

A  characteristic  case  of  tuberculous  disease  of  the  hip  joint  begins 
insidiously.  It  causes  a  slight  limp  and  at  times  a  certain  amount  of 
pain.  In  the  early  stage  of  the  disease  there  is  slight  flexion  of  the 
limb,  usually  combined  with  abduction,  the  instinctive  assumption  of 
the  attitude  of  rest.  As  the  disease  progresses,  the  limb  becomes  less 
capable  of  performing  its  proper  function  ;  the  range  of  painless  motion 
becomes  more  and  more  restricted  and  the  attitude  changes  to  one  of 
increased  flexion  and  adduction,  the  attitude  in  which  the  limb  is  best 
protected  from  injury  and  in  which  it  is  least  capable  of  performing  its 
share  of  normal  work.  Pain  is  more  constant,  abscess  is  often  present, 
and  the  constitutional  effects  of  a  depressing  disease  may  be  apparent. 


250  TUBERCULOUS  DISEASE  OF  THE  HIP  JOIST. 

This  progression  of  symptoms  and  attitudes  is  so  fairly  constant,  that 
hip  disease  is  often  divided  into  stages  corresponding  to  these  early 
and  later  manifestations  of  its  effects.  "When  the  limb  has  reached  the 
position  of  greatest  protection,  when  motion  which  at  first  was  limited 
only  by  the  involuntary  spasm  of  the  muscles  that  are  now  atrophied, 
is  restricted  by  adhesions  and  contractions,  pain  often  ceases  to  be  a 
troublesome  symptom,  the  general  health  improves  and  effective  repair 
begins.  During  the  progressive  stage  erosion  of  the  opposing  surfaces 
of  the  joint  has  advanced,  always  more  rapidly  at  the  points  of  mutual 
pressure  and  friction,  the  upper  and  inner  surface  of  the  head  of  the 
femur  and  the  upper  margin  of  the  acetabulum,  and  here  the  disease 
remains  active  while  repair  progresses  at  the  points  which  have  been 
relieved  from  irritation.  Thus,  in  many  instances,  the  upper  margin 
of  the  acetabulum  is  destroyed  and  a  subluxation  of  the  femur  takes 
place  (Fig.  155),  a  displacement  favored  by  the  attitude  of  flexion  and 
adduction  and  induced  by  pressure  upon  the  limb.  In  some  instances 
there  is  complete  displacement,  and  when  the  diseased  parts  are  thus 
separated  from  one  another  by  this  form  of  pathological  excision,  relief 
of  symptoms  and  practical  recovers'  may  quickly  follow,  although  sin- 
uses leading  to  areas  of  local  disease  or  to  fragments  of  necrosed  bone, 
may  persist  for  many  years. 

Nature's  cure  of  hip  disease  implies  recovery  with  a  shortened  and 
distorted  limb,  a  final  result  which  is  common  enough  even  when 
treatment  has  been  employed  to  explain  the  popular  conception  of  what 
hip  disease  entails.     (Fig.  165.) 

There  are  many  cases  of  hip  disease  in  which  the  primary  focus  in 
the  head  of  the  bone  is  so  limited  in  extent,  that  perfect  functional 
cure  may  result  under  any  form  of  treatment,  or  non-treatment  even. 
And  there  are  others  in  which  the  disease  is  of  such  a  destructive 
character  that  the  result  must  be  disastrous  in  spite  of  treatment.  But 
there  can  be  no  doubt  that  by  early  diagnosis  and  by  efficient  protec- 
tion, a  vast  amount  of  suffering  may  be  prevented,  that  useful  function 
may  be  preserved,  which  would  otherwise  have  been  lost. 

The  object  of  treatment  is  to  prevent  the  symptoms  and  the  effects 
of  the  disease  that  have  been  outlined  as  characteristic  of  the  untreated 
cases.  To  relieve  the  pain  that  depresses  the  vitality  of  the  patient. 
To  relieve  the  muscular  spasm  that  induces  distortion  of  the  limb,  and 
that  stimulates  the  activity  of  the  destructive  process  by  increasing  the 
pressure  and  friction  of  the  diseased  surfaces  of  the  opposing  bones. 
To  correct  and  to  prevent  deformity  and  to  prevent,  as  far  as  may  be 
by  lessening  the  pressure  and  by  restraining  motion,  the  upward  dis- 
placement of  the  femur  that  causes  irremediable  distortion. 

There  are  cases  in  which  radical  removal  of  the  diseased  parts  may 
be  indicated  and  there  are  times  when  acute  symptoms  may  require  ab- 
solute rest  of  the  patient.  But  it  is  evident  in  the  management  of  a 
chronic  tuberculous  disease,  throughout  the  period  of  years  that  may 
elapse  before  cure  is  accomplished,  that  the  requirements  of  treatment 
which  have  been  indicated  must  be  met,  as  far  as  may  be,  by  appli- 
ances that  allow  exercise  in  the  open  air. 


THE  TRACTION  HIP  SPLINT.  251 

Mechanical  Treatment. — The  most  effective  treatment  of  a  diseased 
joint  is'that  which  assures  it  the  most  perfect  rest  and  protection.  If 
the  disease  be  in  the  earliest  stage  and  confined  to  the  interior  of  the 
bone,  rest  offers  the  most  favorable  condition  for  repair  and  for  pres- 
ervation of  the  joint.  If  the  disease  be  further  advanced,  complete 
relief  of  function  affords  an  opportunity  for  nature  to  check  its  prog- 
ress and  to  preserve,  it  may  be,  a  part  of  a  joint  from  invasion.  If 
the  joint  be  already  involved,  rest  offers  the  best  opportunity  for  re- 
pair by  preventing  friction  that  stimulates  the  progress  of  the  disease 
and  increases  its  destructive  effects.  Whatever  checks  or  retards  the 
progress  of  the  disease  correspondingly  relieves  its  symptoms  and  pre- 
vents the  constitutional  depression  and  thus  preserves  the  vital  resist- 
ance, both  local  and  general,  upon  which  the  cure  of  the  disease  ulti- 
mately depends. 

Rest  of  a  diseased  joint  of  the  lower  extremity  necessitates  splinting, 
stilting  and  traction. 

Splintixg  naturally  signifies  the  fixation  that  may  be  attained  by 
the  application  of  a  splint,  extending  a  sufficient  distance  on  either 
side  of  the  part  to  be  fixed. 

Stilting — the  elevation  of  the  foot  from  the  ground  so  that  jar  and 
pressure  on  the  diseased  articulation  may  be  removed. 

Traction — a  sufficient  force  exerted  upon  the  limb  to  overcome  and 
to  control  the  spasmodic  action  of  the  muscles. 

The  knee  joint,  the  junction  of  two  levers  of  similar  size  and  func- 
tion may  be  easily  controlled  or  placed  at  rest  by  means  of  apparatus. 
But  the  hip  joint  is  a  ball-and-socket  joint  which  allows  free  motion 
in  many  directions,  and  being  the  junction  of  the  body  and  the  limb, 
two  segments  of  different  size  and  function,  it  is  especially  difficult  to 
control.  For  this  reason  as  much  as  any  other,  perhaps,  the  treatment 
of  hip  disease  has  been  the  subject  of  controversy  for  many  years. 
And  even  at  the  present  time  one  can  hardly  describe  the  treatment  of 
hip  disease  adequately,  without  contrasting  the  methods  of  treatment 
that  are  in  common  use. 

Such  an  exposition  should  begin  naturally  with  a  description  of 
what  has  long  been  known  as  the  American  treatment,  in  which  trac- 
tion has  always  occupied  the  most  important  place. 

The  Traction  Hip  Splint. — The  traction  hip  splint  consists  of  a  pelvic 
band  and  an  upright.  The  pelvic  band  is  made  of  sheet  steel  about  a 
quarter  of  an  inch  in  thickness  and  one  and  one-eighth  inches  in  width, 
sufficiently  strong  to  support  the  weight  of  the  body  without  yielding, 
bent  into  a  U  shape  to  conform  to  the  pelvis,  but  wide  enough  to  cause 
no  antero-posterior  pressure.  As  Taylor  puts  it,  there  should  be  room 
enough  for  the  pelvis  to  move  freely  in  it.  This  band  embraces  about 
three-quarters  of  the  pelvis  at  a  point  just  above  the  trochanters.  It 
is  covered  with  leather  and  is  provided  with  a  strap  to  complete  the 
circumference.  Upon  the  pelvic  band  four  buckles  are  placed  for  the 
attachment  of  the  perineal  bands.  The  two  buckles  on  the  front  band 
are  placed  directly  above  the  attachments  of  the  adductor  muscles,  on 


252 


TUBERCULOUS  DISEASE  OF  THE  HIP  JOINT. 


either  side  of  the  genitals.  Behind,  the  buckles  are  placed  much  fur- 
ther apart,  somewhat  to  the  outer  side  of  each  ischial  tuberosity,  upon 
which,  in  great  part,  the  weight  of  the  body  is  to  be  supported.  The 
pelvic  band  is  bolted  firmly  to  the  upright  at  a  slight  inclination,  cor- 
responding to  the  inclination  of  the  pelvis.  The  upright  extends  from 
the  top  of  the  trochanter  to  two  or  more  inches  below  the  sole  of  the 
foot.  It  may  be  made  in  one  piece  or  in  two  sections  overlapped  and 
attached  to  one  another  by  screws,  to  allow  for  adjustment.  (Fig.  172.) 
It  is  turned  inward  at  a  right  angle  below  the  foot  and  is  shod  with 
leather  or  rubber.  The  foot  piece  may  be  provided  with  a  windlass 
(Fig.  171),  or  the  traction  may  be  made  by  simple  straps  attached 
on  either  side.  At  about  the  middle  of  the  upright  is  placed  a  sup- 
port of  light  steel  which  is  provided  with  a  broad  leather  strap  for  the 
purpose  of  fixing  the  thigh  to  the  brace  and  supporting  the  knee.  In 
some  braces  a  second  similar  support  is  placed  at  the  upper  part  of  the 
stem ;  in  others  the  knee  is  supported  only  by  a  broad  leather  pad 

which  covers  its  inner  surface  and  is  attached  to  a 
Fig.  171.  cross  piece  on  the  upright  by  straps,  as  in  the  Taylor 

brace.     In  the  Taylor  brace,  which  has  served  as  a 


Fig.  172. 


Fig.  173. 


The  traction  hip  splint  with  over-lapping  upright  and  windlass,  used  at  the  Boston  Children's  Hos- 
pital.   (Bradford  AND  LovETT.) 


model  for  all  similar  appliances,  the  upright  is  a  steel  tube  into  which 
slides  a  rod,  supporting  the  foot  part  of  the  brace,  the  two  parts  being 
joined  with  a  rack-and-pinion  attachment  and  lock,  so  that  the  brace 
may  be  lengthened  or  shortened  by  means  of  a  key.     (Fig.  178.) 


THE  TRACTION  BRACE. 


253 


Traction  Straps. — Traction  upon  the  limb  is  made  by  adhesive  plas- 
ter, preferably  that  known  as  moleskin  (yellow)  plaster  which  is  far 
less  irritating  to  the  skin  than  rubber  plaster. 

These  plasters  should  be  cut  into  a  shape  corresponding  to  the  lat- 
eral aspect  of  the  thigh  and  leg,  thus  :  wide  above  and  narrow  below, 
reaching  from  the  trochanter  on  the  outer,  and  from  the  pubes  on  the 
inner  side,  to  the  malleoli.  (Fig.  195.)  The  lower  ends  are  reinforced 
by  a  second  layer  of  plaster  and  to  them  buckles  are  attached.  The 
plasters  are  then  applied  to  the  limb  and  are  held  in  place  by  a  band- 
age which  is  smoothly  applied  and  then  sewed. 
Fig.  174.  to  prevent  disarrangement.     The  object  of  the 

bandage  is  primarily  to  assure  the  adhesion  of 
the  plaster  and  secondarily  to  keep  it  clean. 
It  can  be  replaced  by  a  properly  fitted  covering 
of  stockinette  or  by  a  stocking  leg. 

Another  method   of  ap- 
FiG.  175.  ply^^g  t^^  plaster,  designed 

to  attain  a  better  hold  upon 
the  limb,  is  that  devised  by 
Taylor,  and  described  by 
him  as  follows  :  "  The  first 
important  object  is  to  seize 
the  leg  in  such  a  manner  as 
to  exert  against  it  an  un- 
yielding force.  This  should 
be  done  in  such  a  manner 
as  will  not  interfere  with 
the  circulation,  nor  injure 
the  knee,  by  unequal  strain 
either  below  or  above  it.  In 
other  words,  the  whole  leg 
should  be  grasped  in  such 
a  manner  that  the  knee  will 
be  supported.  It  may  be 
done  as  follows  :  A  strip 
of  adhesive  plaster  long 
enough  to  reach  from  the 
waist  to  the  foot,  and  from 
three  to  five  inches  wide  at 
the  upper  and  about  one-third  that  width  at  the  lowqr  end,  is  taken  and 
cut  into  five  tails  as  shown  in  accompanying  illustration.  (Fig.  174.) 
A  piece  from  four  to  six  inches  long  is  cut  from  the  center  tail  and 
added  to  the  lower  end  to  strengthen  it ;  and,  if  the  patient  be  strong,  one 
or  two  more  pieces  are  laid  on  the  same  place,  where  a  buckle  is  attached. 
Two  similar  straps  are  prepared,  one  for  the  inside  and  one  for  the  outside 
of  the  leg,  and  laid  against  the  lateral  aspects  of  the  leg,  the  ends  with  the 
buckles  beginning  about  two  inches  above  the  internal  and  external 
malleoli,  and  the  center  tails  reaching  the  entire  length  of  the  leg  and 


C.  F.  Taylor's  method  of  applying  adhesive  plaster. 


254 


TUBERCULOUS  DISEASE   OF  THE  HIP  JOINT. 


Fig.  176. 


thigh,  to  the  perineum  inside  and  the  trochanter  on  the  outside.  The 
lower  strips  or  tails  are  then  wound  spirally  around  the  leg  to  the  pelvis 
and  afterward  the  other  two  pairs  of  tails,  which  are  cut  down  to  just 
above  the  knee,  are  also  wound  about  the  thigh  in  the  same  manner. 
When  completed,  the  thigh  is  involved  in  a  network  of  strips  of  adhesive 
plaster,  which  act  equally  and  without  pressure  on  the  whole  surface. 
The  leg  has  about  one-fourth  of  the  attachments,  and  the  thigh  three- 
fourths,  which  is  found  to  be  the  right  proportion  to  protect  the  knee 
equally  from  compression  or  strain.  A  few  turns  of  the  roller  band- 
age are  then  made  around  the  ankle  just  under  the  lower  ends  of  the 

straps,  which  serves  as  a  protection  to  the 
flesh  under  the  buckles,  and  then  it  is  con- 
tinued over  the  straps  on  the  whole  leg. 
Thus  prepared,  the  patient  is  ready  for  the 
splint." 

At  the  Boston  Children's  Hospital  the 
lower  ends  of  the  adhesive  straps  termi- 
nate in  tapes  that  extend  below  the  foot  for 
attachment  to  the  windlass,  which  is  used 
with  the  cheaper  form  of  brace. 

Perineal  Bands. — Perineal  bands  are 
made  by  covering  a  firm,  wide,  unyielding 
band  of  webbing  with  several  folds  of 
blanket  or  similar  material  and  then  bind- 
ing it  smoothly  with  canton  flannel.  These 
are  made  in  different  lengths  and  sizes, 
as  may  be  required. 

The  "  High  Shoe." — The  best  and  light- 
est material  for  raising  the  shoe  worn  on 
the  sound  foot  to  correspond  with  the 
brace  is  cork,  and  the  ordinary  thickness 
is  two  and  a-half  inches.  A  good  and 
cheap  substitute  may  be  made  of  light 
wood  provided  with  a  leather  sole,  and 
in  certain  cases  a  patten  of  metal  may  be 
used. 

The    Application  of  the    Traction   Hip 
The  traction  hip  brace.   Original  form.   Splint. — The  traction  bracc  is  applied  in 

the  following  manner : 
The  patient  lying  upon  his  back,  the  pelvic  band  is  first  adjusted 
and  strapped  about  the  body.  The  perineal  supports  are  then  drawn 
firmly  into  place  so  that  pressure  on  the  upright  does  not  move  the 
pelvic  band  from  its  proper  position  just  above. the  trochanter.  The 
brace  is  then  pressed  upward  against  the  resistance  of  the  perineal 
bands,  while  the  leg  is  at  the  same  time  drawn  downward  and  is  fixed 
by  attaching  the  straps  to  the  buckles  at  the  ends  of  the  adhesive 
plasters.  If  the  brace  is  provided  with  a  windlass  or  ratchet,  further 
traction  is  applied  to  the  point  of  tolerance  by  means  of  the  key,  care 


THE  TRACTION  BRACE. 


255 


being  taken  in  adjusting  the  brace  that  it  does  not  project  so  far  be- 
low the  foot  as  to  more  than  equal  the  extra  length  provided  by  the 
high  shoe  on  the  sound  side.  The  knee  band  is  then  adjusted  and  in 
many  instances  a  strap  is  placed  about  the  ankle  and  the  brace  to  as- 
sure greater  security.  The  shoe  is  then  put  on,  the  leg  clothing  is 
drawn  over  the  brace  and  the  patient  is  allowed  to  stand.  If  in  walk- 
ing the  patient  is  inclined  to  tilt  the  foot  downward  and  to  bear  the 

Fig.  177. 


c 


The  Judson  brace.  This  has  but  one  perineal  band  and  the  upright  is  bolted  flrnily  to  the  pelvic  band. 


weight  on  the  toe,  a  heel  strap  is  attached  to  the  foot  piece  to  hold  the 
foot  in  the  horizontal  position. 

By  means  of  this  brace  the  weight  is  borne  entirely  upon  the  per- 
ineal bands,  thus  the  joint  is  relieved  from  pressure  and  from  jar. 
These  perineal  bands  should  be  accurately  adjusted  to  pass  upward,  in 
front,  parallel  to  one  another  on  either  side  of  the  genitals,  in  order  to 
avoid  pressure  on  the  adductor  region  of  the  thighs ;  while  behind, 
they  turn  diagonally  outward  in  order  to  pass  over  the  tuberosities, 
which  are  best  adapted  for  weight  bearing. 


256 


TUBERCULOUS  DISEASE  OF  THE  HIP  JOINT. 


In  the  original  Taylor  hip  brace  the  pelvic  band  is  bolted  to  the 
upright  in  a  manner  to  allow  antero-posterior  motion,  and  the  inclina- 
tion of  the  pelvic  band  is  regulated  by  a  strap  attached  to  the  upright. 
(Fig.  176.)  This  facilitates  adjustment  when  the  limb  is  flexed  to  a 
marked  degree.  This  brace  has  been  modified  by  Taylor  by  shortening 
and  changing  the  shape  of  the  pelvic  band  for  the  use  of  but  one  peri- 
neal support  (Fig.  201) ;  and  a  similar  form  of  brace  is  used  by  Judson. 
The  shortened  pelvic  band  lessens  the  restraint  of  the  brace  upon  the 
motion  of  the  limb,  and  seems  to  offer  little  compensating  advantage. 

Before  the  traction  brace  is  used  in  ambulatory  treatment,  distortion 
of  the  limb,  if  it  be  present,  should  be  reduced ;  or  if  the  disease  be 
particularly  acute,  preliminary  rest  in  bed,  until  the  subsidence  of  the 
symptoms,  is  advisable. 

The  Reduction  of  Deformity  by  Means  of  the  Traction  Brace  .^The 
patient  lies  in  bed  upon  a  firm  mattress ;  the  distorted  limb  is  then 
raised  to  slightly  more  than  a  sufficient  angle  to  relax  the  contracted 

Fig.  178. 


The  reduction  of  flexion  by  means  of  the  traction  hip  splint.     (C.  F.  Taylor.) 


muscles  and  to  straighten  the  lumbar  lordosis ;  it  is  then  abducted  or 
adducted  if  necessary  so  that  the  level  of  the  pelvis  is  restored.  The 
pelvic  band  is  made  to  conform  to  this  greater  relative  inclination  of 
the  pelvis  by  lengthening  the  posterior  strap  ;  the  brace  is  then  applied, 
the  limb  being  held  in  the  attitude  of  deformity  by  a  sling  or  support 
(Fig.  178),  and  as  much  traction  as  the  patient  can  tolerate  is  exerted 
by  lengthening  the  upright.  The  direct  traction  exerted  by  the  brace 
may  be  reenforced  by  means  of  a  cord  running  over  a  pulley  at  the  foot 
of  the  bed,  in  the  line  of  the  brace,  to  which  a  weight  of  ten  or  more 
pounds  (Fig,  1 79)  is  attached.  Thus  the  pressure  of  the  perineal  bands 
is  somewhat  lessened.  Efficient  traction  will  quickly  reduce  recent  de- 
formity caused  by  muscular  contraction,  and  as  this  is  lessened  the  posi- 
tion of  the  limb  is  correspondingly  changed,  until  it  lies  extended  and 
parallel  with  its  fellow.  If  adduction  be  combined  with  flexion  the 
perineal  band  on  the  side  opposite  to  the  disease  is  tightened  from  time 
to  time,  or  a  direct  push  against  the  opposite  adductor  region  is  exerted 
by  means  of  a  bar  attached  to  the  brace  opposite  the  knee.     (Fig.  200.) 


THE  TRACTION  BRACE.  257 

In  ordinary  cases  the  deformity  may  be  reduced  by  this  means  in  from 
two  to  six  weeks. 

The  brace  should  be  worn  day  and  night.  The  perineal  bands  may 
be  loosened  at  times  to  allow  for  bathing  the  skin  with  alcohol,  and  for 
powdering,  in  order  that  the  skin  may  be  kept  dry  ;  but  at  such  times, 
if  the  disease  be  acute,  manual  traction  should  be  made  until  the  brace 
has  been  readjusted.  The  adhesive  plasters,  if  of  moleskin,  may  often 
remain  in  position  for  three  months  or  longer.  When  they  are  re- 
moved the  limb  is  gently  bathed  with  alcohol.  Excoriations  are  un- 
usual unless  rubber  plaster  is  used.  If  the  skin  is  abraded  the  part 
should  be  powdered  with  boracic  acid  and  protected  from  the  j^laster 
by  a  layer  of  gauze. 

The  Relative  Efficiency  of  the  Traction  Hip  Splint. — 
In  analyzing  the  action  of  this  brace  it  is  evident  at  once  that  it  is 
thoroughly  effective  as  a  stilt.  It  is  eifective  as  a  traction  appliance, 
in  the  sense  of  relieving  muscular  tension,  in  direct  proportion  to  the 

Fig.  179. 


A  method  of  reducing  flexion  in  hip  disease.  The  brace  is  adjusted  to  the  angle  of  deformity  and 
in  addition  to  the  direct  traction  of  the  apparatus  weights  are  attached  to  the  brace  itself.  In  the 
illustration  counter-traction,  by  means  of  perineal  bands  attached  to  the  head  of  the  bed,  is  shown. 

care  that  is  exercised  in  its  adjustment.  Tr^tion  by  this  appliance 
may  be  made  constant  and  effective,  even  to  the  point  of  practical  fix- 
ation while  the  patient  is  in  bed,  or  when  crutches  are  used,  in  ambu- 
latory treatment.  But  when  the  apparatus  is  used  as  a  walking  brace, 
as  was  designed  by  its  inventor,  constant  traction  is  not  exerted,  for 
the  traction  straps  alternately  relax  and  tighten  when  the  weight  of 
the  body  falls  upon  and  leaves  the  brace  in  walking.  When  the 
brace  is  off  the  ground  the  joint  is  subjected  to  the  traction  that  the 
brace  exerts,  plus  its  weight,  as  contrasted  with  cessation  of  traction 
and  the  relief  from  the  weight  when  the  brace  supports  the  body  at 
the  alternate  step.  Thus  the  critics  of  the  brace  assert,  in  somewhat 
exaggerated  language,  that  it  exercises  a  pumping  action  on  the  joint. 
As  a  matter  of  fact,  the  observation  of  patients,  under  treatment  by 
this  method,  will  show  that  little  actual  traction  is  exerted  in  the  ordi- 
nary cases  ;  that  the  so-called  traction  really  serves  principally  for  the 
adjustment  of  the  brace,  which  by  its  weight,  exercises  a  certain  inter- 
mittent traction  during  locomotion.  The  hold  of  the  encircling  band 
17 


258  TUBERCULOUS  DISEASE  OF  THE  HIP  JOINT. 

upon  the  pelvis  assures  a  considerable  restriction  of  motion,  but  what- 
ever splinting  action  it  may  have  depends  upon  the  degree  of  traction, 
which  is  never  effective  enough,  however,  to  prevent  a  certain  amount 
of  motion.  This  point  is  illustrated  by  the  experiments  of  Lovett,^ 
which  are  described  by  him  as  follows  : 

"  In  these  experiments  a  long-traction  splint  was  fitted  with  a  self- 
registering  pencil,  by  means  of  which  motion  at  the  hip  joint  was 
recorded  upon  the  skin  over  the  ilium.  This  was  done  simply  by 
carrying  the  shaft  up,  so  that  it  held  the  pencil  perpendicularly  to  the 
skin.  A  splint  fitted  with  this  register  was  applied  to  a  boy  with 
normal  hip  joints,  and  traction  was  made  up  to  the  usual  point,  being 
about  three  pounds  and  a-half,  as  registered  by  a  spring  balance  in- 
serted in  the  extension  straps.  AVith  this  splint  on,  the  boy  was 
allowed  to  walk,  and  it  was  found  that  the  hip  described  an  arc  of 
thirty-five  degrees  of  joint  motion.  In  sitting  down  and  rising,  an  arc 
of  similar  extent  was  described.  In  another  case  with  normal  hip 
joints  the  motion  was  found  greater,  and  the  register  showed  a  motion 
of  forty  degrees.  With  a  very  severe  amount  of  traction — so  much  so 
that  it  was  almost  unendurable — motion  of  fifteen  degrees  was  recorded. 
This  apparatus  was  first  tested  by  being  applied  to  a  patient  with 
anchylosis  of  the  hip,  when  it  was  found  that  no  motion  was  recorded, 
the  register  marking  by  a  dot.  These  experiments  certainly  seem  to 
show  that  to  a  healthy  hip  joint  the  long-traction  splint  affords  very 
imperfect  fixation,  and  it  may  be  inferred  that  to  a  diseased  joint 
equally  poor  support  is  afforded," 

The  fact  must  be  borne  in  mind  that  the  traction  hip  splint  was 
not  intended  to  be  a  fixation  or  splinting  appliance.  On  the  contrary, 
Davis  its  inventor,  Taylor,  who  changed  it  into  a  practicable  form 
and  Sayre,  who  further  modified  it,  each  believed  that  motion,  except 
when  the  joint  was  fixed  by  muscular  spasm,  was  desirable. 

''The  first  splint,  as  well  as  all  my  modifications,  admits  of  free 
motion  of  the  diseased  joint,  but  rigidly  excludes  all  friction  of  the 
diseased  surfaces  upon  one  another."  ^     (Davis.) 

"  Motion  without  friction  is  not  only  not  injurious,  but  it  is  highly 
beneficial."  ^     (Taylor.) 

"  For  the  ligaments  around  a  joint  will  become  fibro- cartilaginous 
or  even  osseous,  if  motion  is  denied  them,  particularly  if  a  chronic  in- 
flammation is  going  on  within  the  joint  with  which  they  are  connected. 

"  As  Dr.  Davis  is,  I  believe,  the  first  person  who  constructed  an  in- 
strument embracing  these  important  advantages,  extension  with  mo- 
tion, I  have  given  him  full  credit  for  the  same,  etc."  ^     (Sayre.) 

Motion  without  friction  in  this  sense  would  seem  to  imply  the  actual 
separation  of  the  femur  from  the  acetabulum,  or  distraction  as  distinct 
from  traction. 

IE.  W.  Lovett,  X.  Y.  Med.  Jour.,^Aug.  8,  1891. 

2  Davis,  Conservative  Surgery,  1867,  p.  214. 

3  Taylor,  The  MechanicalTreatment  of  Disease  of  the  Hip  Joint,  p.  15,  1873. 
*  Sayre,  Lectures  on  Orthopa?dic  Surgery,  p.  260,  1879. 


THE  TRACTION  BRACE.  259 

That  actual  distraction  is  possible  at  the  hip  joint  both  in  health 
and  disease  is  proved  by  the  experiments  of  Brackett  ^  and  by  those  of 
Bradford  and  Lovett.  These  experiments  show  that  a  traction  force 
from  ten  to  t^Yenty  pounds  is  required  to  cause  one-eighth  to  one-quar- 
ter of  an  inch  of  actual  lengthening  of  the  limb,  even  in  childhood  ;  it 
is,  therefore,  to  say  the  least,  unlikely  that  the  feeble  and  intermittent 
traction  exerted  by  a  hip  splint,  when  used  as  an  ambulatory  support, 
can  be  sufficient  to  separate  the  bones  from  one  another  and  thus  to 
allow  motion  without  friction,  as  was  originally  claimed  for  this  appara- 
tus. In  fact  it  would  appear  that  the  claim  that  motion  was  of  posi- 
tive benefit  to  the  diseased  joint  was  afterwards  modified  by  the  up- 
holders of  this  method  of  treatment  to  a  negative  assertion  of  its 
harmlessness,  for  example  : 

"  If  the  disease  permits  a  certain  amount  of  motion  at  the  affected 
articulation,  motion  within  the  limits  set  by  nature  is  not  harmful."  ^ 
(Shaffer.) 

This  statement  would  seem  to  imply  that  the  motion  permitted  by 
the  apparatus  might  be  varied  in  accordance  with  the  degree  of  re- 
striction that  a  particular  case  presented,  provided  that  this  motion 
were  restricted  to  the  limit  set  by  nature  ;  but  in  actual  practice  the 
same  form  of  brace  is  applied,  and  with  the  same  adjustment,  in  every 
case ;  or  as  it  is  stated  in  a  paper  on  the  final  results  of  the  mechan- 
ical treatment  by  this  apparatus  in  dispensary  practice,  under  Shaf- 
fer's direction  :  "  In  each  case  reported,  a  Taylor  traction  splint  was 
applied  soon  after  the  first  examination.  =^  *  *  The  patient,  unless  re- 
cumbency was  necessary  to  overcome  a  malposition  of  the  limb  or  un- 
less the  symptoms  were  so  acute  as  to  demand  rest,  was  allowed  almost 
unlimited  exercise  in  the  open  air."  ^  Yet  it  may  be  inferred  from  the 
report  of  the  final  results  in  these  cases  that  in  spite  of  the  protection, 
which  in  many  instances  must  have  restricted  motion  within  the  limits 
present  at  the  first  examination,  the  range  of  motion  became  more  and 
more  restricted,  for  in  16  of  35  cases  reported,  anchylosis  resulted  ; 
and  in  seven  others  the  motion  was  less  than  ten  degrees.  Thus  in 
74  per  cent,  of  the  cases,  practical  fixation  of  the  joint  was  found  on 
the  final  examination. 

In  criticising  these  statistics  it  must  be  borne  in  mind  that  the  pa- 
tients were  treated  under  all  the  disadvantages  of  dispensary  practice, 
and  that  the  final  usefulness  of  a  limb  is  by  no  means  in  proportion  to 
the  freedom  of  motion  that  may  be  preserved  ;  still  with  these  reserva- 
tions it  can  hardly  be  claimed  that  the  proportion  of  absolute  or  par- 
tial anchylosis  would  have  been  greater  than  this  had  any  other  system 
of  treatment  been  employed. 

At  the  present  time  the  theory  that  motion  of  a  diseased  joint  is  of 
benefit,  or  that  it  is  even  harmless,  has  few  supporters  even  among 

1  Brackett,  Trans.  Am.  Orth.  Ass'n,  Vol.  II.;  Bradfol-d  and  Lovett,  N.  Y.  Med. 
Jour.,  Aug.  4,  1894. 

2 Shaffer,  Trans.  Am.  Orth.  Ass'n,  Vol.  II.,  p.  100. 

^  On  the  Ultimate  Results  of  the  Mechanical  Treatment  of  Hip  Joint  Disease. 
Shaffer  and  Lovett,  N.  Y.  Med.  Jour.,  May  21,  1887. 


260  TUBERCULOUS  DISEASE  OF  THE  HIP  JOINT. 

those  who  use  the  traction  brace  exckisively.  Ou  the  contrary,  the 
motion  that  is  recognized  as  unavoidable  with  the  use  of  the  apparatus 
is  excused  because  of  the  practical  efficiency  of  the  brace  and  because  it 
is  believed  that  no  more  effective  rest  can  be  attained  by  any  other 
method  of  ambulatory  treatment. 

In  all  acute  cases  a  period  of  rest  in  bed  with  traction  to  the  point 
of  actual  distraction,  is  advised.  AVhen  ambulation  is  resumed  the 
braced  limb  is  made  pendant  by  means  of  the  high  shoe  and  crutches, 
so  that  uninterrupted  traction  may  still  be  exerted,  and  the  brace  is 
only  used  as  a  supporting  appliance  when  the  symptoms  indicate  that 
the  disease  is  quiescent. 

Although  this  modification  of  treatment  was  not  followed  by  Tay- 
lor, still  in  his  later  writings  he  states  that  motion  is  of  advantage 
only  in  the  stage  of  recovery.  And  it  is  very  evident  that  his  success 
was  due  to  the  extreme  care  which  he  exercised  in  the  supervision  of 
the  patients,  and  in  adapting  treatment  to  the  varying  phases  of  the 
disease,  rather  than  to  any  theory  that  he  may  have  advocated.^ 

As  has  been  stated,  treatment  by  the  long-traction  brace  by  means 
of  which  motion  ^nthout  friction  was  at  one  time  claimed  to  be  possi- 
ble, and  in  which  traction  is  the  distinctive  feature,  is  sometimes  called 
"  The  American  Treatment  of  Hip  Disease."  In  this  sense,  the  direct 
splinting  of  the  joint  without  traction,  by  means  of  the  Thomas  brace, 
might  be  called  in  distinction  "  The  English  Treatment." 

The  Thomas  Treatment  of  Hip  Disease. — H.  O.  Thomas,"  of  Liverpool, 
writing  at  a  time  when  in  America  it  was  generally  believed  that  motion 
was  essential  to  the  well-being  of  a  diseased  joint,  and  when  fixation 
was  supposed  to  predispose  to,  or  to  actually  induce,  anchylosis,  states 
"  that  continuity  of  extension  j^er  -se  is  not  a  remedy  in  hip  joint  disease  ; 
in  its  application  it  involves  unavoidably  a  fractional  degree  of  fixation 
which  is  sufficient  to  mask  the  evil  of  this  ridiculous  malpractice." 

The  conclusions  on  which  his  treatment  is  founded  are  these  :  "  The 
main  obstacle  to  the  cure  of  an  inflamed  joint  is  the  friction  and  pressure 
of  its  surfaces  ;  consequently  the  attainment  of  rest,  that  is  of  immobility 
of  the  articulations,  ought  to  be  the  principle  which  should  guide  the 
treatment.  Pressure  and  concussion  are  less  to  be  feared  than  friction. 
Effectual  rest  can  only  be  obtained  by  mechanical  treatment  and  for 
this  purpose  the  appliances  which  I  here  recommend  are  effectual. 
The  more  an  inflamed  joint  is  moved  the  stiffer  does  it  become ;  while 
the  more  effectually  it  is  fixed,  the  sooner  and  the  more  completely  is  its 
capability  of  movement  restored.  To  insure  permanency  of  cure,  the 
control  should  be  maintained  for  a  period  beyond  the  time  when  resolu- 
tion has  taken  place.  This  prolonged  arrest  of  a  joint's  movements,  for 
even  an  unnecessarily  long  period,  I  have  never  found  to  do  harm." 

The  splint  used  by  Mr.  Thomas  to  carry  out  these  principles  effec- 
tively is  described  by  him  substantially  as  follows  : 

'Boston  Med.  and  Surg.  Jour.,  March  6,  1879. 

2  Diseases  of  the  Hip,  Knee  and  Ankle  Joints,  treated  by  a  new  and  effective 
method,  1875,  p.  10. 


THE  THOMAS  BRACE. 


261 


A  flat  piece  of  malleable  iron,  three-quarters  of  an  inch  wide  and 
three-sixteenths  of  an  inch  thick  for  children,  and  one  inch  by  one- 
quarter  inch  for  adults,  long  enough  to  extend  from  the  lower  angle  of 
the  scapula  to  the  middle  of  the  calf,  forms  the  upright.  This  is 
fitted  to  the  body  of  the  patient,  passing  from  the  lower  angle  of  the 
scapula,  in  a  perpendicular  line,  downward,  over  the  lumbar  region, 
across  the  pelvis,  slightly  external,  but  close  to  the  posterior  spinous 
process  of  the  ilium  and  the  prominence  of  the  buttock,  along  the 
course  of  the  sciatic  nerve  to  a  point  slightly  internal  to  the  calf  of 
the  leg.  It  must  be  carefully  modelled  to  this  track.  The  lumbar 
portion  of  the  upright  must  be  invariably  almost 
a  plane  surface,  but  it  must  be  twisted  slightly  on 
^i;  vfji  ^^r:^  its  long  axis  at  the  junction  of  the  upper  and 
yUP  \^       middle  third,  so  that  the  anterior  surface  of  the 

lower  section  may  look  slightly  outward  to  cor- 
respond to  the  contour  of  the  buttock  and  thigh. 
A  second  and  double  bend  is  made  in  the  upright 
at  the  point  where  it  passes  the  buttock,  so  that  the 
thigh  portion  lies  on  a  slightly  higher  plane  than 

Fig.  181. 


Fig.  180. 


The  splint  in  its  simplest 
form,  not  yet  padded  or  cov- 
ered.     (ElDLON.) 


The  Thomas  hijj  splint,  covered  and  fitted  with  shoulder  straps. 

(ElDLOS  AND  JOUES.) 


the  body  part,  but  parallel  mth  it.    The  upright  is  then  provided  with 
chest,  thigh  and  leg  bands. 

The  chest  band  is  of  hoop  iron  one  and  a-half  by  one-eighth  of  an 
inch.  This  is  bent  into  an  oval  to  correspond  with  the  shape  of  the 
chest,  being  four  inches  less  than  its  circumference  at  this  point  if  the 
patient  be  an  adult,  and  of  a  corresponding  size  for  a  child.  This 
band  is  riveted  to  the  upper  extremity  of  the  brace,  so  that  one-third 
of  its  length  shall  be  on  one  side  of  the  disease  and  two-thirds  on  the 
other.  The  thigh  band  and  leg  bands  are  of  similar  material,  three- 
quarters  by  one-eighth  of  an  inch  in  size.  The  thigh  band,  in  length 
equal  to  two-thirds  of  the  circumference  of  the  thigh,  is  fastened  to  the 
upright  at  a  point  one  to  two  inches  below  the  buttock,  and  the  calf 
band,  equal  in  length  to  half  the  circumference  of  the  leg  at  the  calf, 


262 


TUBERCULOUS  DISEASE  OF  THE  HIP  JOINT. 


is  riveted  to  the  lower  extremity  of  the  brace.  Both  the  thigh  and  leg 
bands  are  attached  to  the  brace  at  points  slightly  to  the  inner  side  of 
the  center,  so  that  the  outer  arm  of  each  band  is  somewhat  longer  than 
the  inner.  The  brace  is  padded  with  thin  boiler  felt  and  is  covered 
smoothly  with  basil  leather.  In  fitting  the  brace  to  the  patient  the 
long  part  of  the  chest  band  should  be  made  to  hug  the  body  closely, 
w^hile  the  short  arm  should  be  somewhat  away  from  it.  The  anterior 
surface  of  the  thigh  part  of  the  upright  should  have  a  perceptible  out- 
ward twist  and  should  be  somewhat  on  the  inner  side  of  the  popliteal 
space.  Thus  the  instrument  is  prevented  from  rotating  outward  and 
becoming  a  side  splint.  The  chest  band  is  closed  with  a  strap  and 
buckle  and  suspended  by  shoulder  straps  and  the  leg  between  the  two 

Fig.  182. 


Method  of  changing  the  line  of  pressure  on  the  skin  from  the  Thomas  hip  splint.  (Ridlon  and  Jones.) 

bands  is  attached  to  the  brace  by  means  of  a  flannel  bandage.  Ridlon 
states  that  in  practice  this  bandage  is  usually  replaced  by  a  strip  of 
basil  leather  passed  across  the  front  of  the  leg  close  down  to  the  upper 
border  of  the  patella,  thence  backward  and  dow-nward  to  the  stem  of 
the  splint  and  pinned  to  the  covering,  so  that  any  downward  working 
of  the  splint  would  be  brought  to  bear  on  the  quadriceps  femoris  mus- 
cle. The  shoulder  straps  also  may  be  replaced  by  a  single  bandage 
looped  about  the  upper  part  of  the  stem.  (Fig.  182.)  This  bandage  is 
twisted  for  a  length  of  about  six  inches,  then  separated,  the  ends  being 
carried  over  the  shoulder,  passed  through  holes  in  the  corresponding 
ends  of  the  chest  band  where  they  are  knotted,  and  finally  the  two  ends 
are  tied  to  one  another  completing  the  circumference  of  the  chest  band. 
This  brace  is  fitted  by  the  surgeon  directly  to  the  patient's  body  as 


THE  THOMAS  BRACE. 


263 


Fig.  183. 


he  stands  erect.  If  the  limb  be  already  flexed,  the  foot  is  raised  by- 
blocks  iuntil  the  lumbar  lordosis  is  straightened ;  the  brace  is  then  ad- 
justed to  the  angle  of  deformity  and  is  applied  in  the  usual  manner. 

The  brace  is  made  of  iron  because  it  is  less  elastic  than  steel  and 
because  it  can  be  more  easily  twisted  by  wrenches.  It  must  be  heavy 
and  strong  in  order  to  splint  the  part  effectively  and  it  can  only  be  an 
effective  splint  when  it  is  fixed  in  its  proper  position  and  exercises 
direct  pressure  upon  the  hip  joint.  In  cases  in  which  the  brace  has 
been  properly  employed  a  deep  furrow  should  be  seen  in  the  buttock 
directly  over  the  neck  of  the  femur.  Once  fitted  to  the  patient  it  is 
changed  only  at  intervals  and  always  by  the  surgeon  who  is  particularly 
careful  not  to  move  the  limb  during  the  active  stage  of  the  disease. 

The  double  Thomas  hip  splint  is  made  by  joining  two  single  splints. 
These  are  riveted  to  the  chest  band  above  and  are  connected  at  the 
lower  ends  by  a  crossbar,  unless  the  brace  is  to  be  used  in  the  reduc- 
tion of  deformity.  Care  must  be 
taken  that  the  uprights  pass  to  the 
outer  side  and  not  directly  over  the 
posterior  superior  spines  of  the  ilium. 

The  Reduction  of  Deformity  by  the 
Thomas  Method. — Preferably  in  the 
treatment  of  children  the  double 
brace  is  applied,  the  sound  limb  being 
fixed  in  the  extended  position  while 
the  flexed  limb  is  supported  by  the 
other  arm  of  the  brace,  bent  to  the 
angle  of  deformity.  The  patient  is 
confined  to  the  bed  and  as  the  mus- 
cular spasm  relaxes  under  the  in- 
fluence of  enforced  rest,  the  brace  is 
straightened  slightly  by  wrenches 
from  time  to  time,  at  a  point  opposite 
the  joint,  to  conform  to  the  improved 
position  until  symmetry  is  restored. 
In  resistant  cases  this  gradual  relax- 
ation is  hastened  by  straightening  the 
brace  somewhat  at  intervals,  to  which 
the  attached  leg  must  conform — a 
gradual  forcible  reduction  of  de- 
formity.^ 

The  treatment  is  divided  by  Mr. 
Thomas  into  stages. 

1 .  A  preliminary  stage  of  rest  in 
bed  for  the   reduction  of  deformity  and  to  allow  for  subsidence  of 
acute  symptoms. 

1  Ridlon  forces  the  flexed  limb  to  conform  to  the  straight  Thomas  brace  unless  the 
deformity  is  extreme.  This  is  made  possible  by  an  exaggeration  of  the  lumbar  lordosis 
and  by  a  corresponding  increase  of  intra -articular  pressure  as  illustrated  by  Marsh's 
diagram  (Fig.  183). 


Thomas  splint  applied  with  patten  and  crutches. 


264 


TUBERCULOUS  DISEASE  OF  THE  HTF  JOINT. 


2.  The  patient  is  then  allowed  to  go  about  on  crutches  wearing  an  iron 
patten  at  least  four  inches  in  height  under  the  sound  foot.     (Fig.  183.) 

3.  When  all  symptoms  of  disease  have  subsided  and  when  atrophy 
of  the  muscles  is  marked  the  brace  may  be  removed  at  night. 

4.  The  brace  is  finally  discarded  but  the  patten  and  crutches  are 
still  used  in  walking. 

According  to  Ridlon  ^  the  records  of  Mr.  Thomas  show  the  average 
time  of  confinement  to  the  bed  to  be  twenty-two  weeks,  and  the  aver-, 
age  duration  of  treatment  twenty-one  months. 

It  is  stated  by  Eidlon  ^  that  in  actual  practice  these  principles  were 
not  carried  out,  for  nearly  all  the  children  treated  under  Thomas' 
direction  at  the  time  his  observations  were  made,  were  walking  about 
without  the  high  patten  and  crutches,  even  before  the  deformity  had 
been  overcome  and  while  muscular  spasm  and  pain  persisted. 

This  was,  however,  probably  an  exigency  of  practice  among  the 
poor,  and  at  all  events  it  is  in  line  with  Thomas'  contention  that 
pressure  and  concussion  are  less  harmful  than  friction. 

Modifications  of  the  Thomas  Brace. — Although  not  so  stated  in  his 
book,  Thomas  used  at  times  a  short  brace  extending  only  to  the 
lower  part  of  the  thigh,  thus  permitting  motion  at  the  knee.  This 
was  apparently  designed  as  a  convalescent  splint,  although  its  use  was 

Fig.  184. 


A  form  of  Thomas  brace  employed  in  the  treatment  of  infants.    The  screws  at  the  lower  extremity 
are  arranged  to  permit  the  addition  of  a  foot  piece  for  traction. 


not  restricted  to  that  class  of  cases.  In  certain  cases  a  strip  of  iron, 
"  the  nurse,"  was  screwed  to  the  lower  extremity  of  the  long  brace, 
prolonging  it  beyond  the  foot  in  order  to  prevent  the  patient  from 
bearing  weight  upon  the  limb. 

The  Thomas  brace,  so  effective  in  preventing  and  overcoming  flexion 
deformity,  is  correspondingly  inefficient  in  antagonizing  lateral  distor- 
tion. In  fact  in  twenty-four  of  the  fifty-eight  patients  examined  by 
Ridlon,^  adduction  was  present ;  a  larger  proportion,  it  would  appear, 
than  would  be  found  in  a  like  number  of  cases  under  treatment  with 
the  traction  brace.     This  tendencv  to  lateral  distortion  mav  be  sruarded 

*  *  o 

1  Trans.  Am.  Orth.  Ass'n,  Vol.  I.,  p.  17. 

2  A  report  of  62  cases  of  Hip  Disease  observed  in  tlie  practice  of  Hugh  Owen  Thomas. 
K  Y.  Med.  Jour.,  Oct.  4,  1890. 

^  Loc.  cit. 


THE  SPICA  BANDAGE. 


'-'65 


against  by  placing  a  half  band  of  material  similar  to  the  chest  band, 
about  the  side  of  the  pelvis  ;  on  the  same  side  for  adduction,  on  the 
opposite  side  for  abduction  of  the  limb. 

The  Thomas  brace  has  a  great  advantage  over  other  appliances  in 
its  simplicity.     It  can  be  made  by  a  blacksmith  and  it  must  be  fitted 
by  the  surgeon.     This  fitting  requires  great  care.     In  the  words  of 
Mr.    Thomas,    "the  fitting  al- 
though sometimes  successful  in  Fig.  185. 
one    visit,  may  at    other   times 
occupy  many  days.    The  surgeon 
should    mould,   by  reducing  or 
increasing   the    various    curves, 
until   the  instrument    ceases   to 
tend  to  rotate,  and  at  none  of  its 
angles  irritates  the  patient."    He 
concludes  in  a  general  answer  to 
the  criticisms  that  have  always 
been  made  on  the  difficulty  of 
adjustment  of  the  appliance,  as 
follows  :    "  What  I  can  invari- 
ably   do    must    be    possible    to 
others." 

Treatment  by  the  Plaster  Band- 
age.— A  third  method  of  treat- 
ment is  that  by  means  of  the 
plaster  bandage  without  crutches 
or  high  shoe.  This  is  simple 
splinting  with  whatever  protec- 
tion from  concussion  the  sup- 
port may  assure. 

This  treatment  might  be  called 
the  German  method,  if  the  trac-  ; 
tion  hip  splint  and  the  Thomas  \ 
brace  are  to    be    designated    as; 
American  and  English. 

As  used  in  the  Surgical  Clinic 
at  Berlin,  the  plaster  bandage  is 
applied  from  the  line  of  the  nip- 
ples to  include  the  foot,  the  limb 
being  fixed  in  an  attitude  of 
slight  flexion,  abduction  and  out- 
ward  rotation.     As    a  rule  the 

first  bandage  is  applied  under  aufesthesia  for  the  purpose  of  relaxing 
the  muscular  contraction  and  facilitating  the  application.  If  nutritive 
shortening  of  the  muscles  is  present,  sufficient  force  is  employed  to 
overcome  the  deformity.  The  spica  is  renewed  at  intervals  of  from 
two  to  four  months.  When  the  disease  is  cured  and  the  bandage  is 
finally  removed,  traction  at  night  is  employed  for  a  time,  by  means  of  a 


A  ijlaster  t-iiicii  bin  ch.ge.     'I  he  di)ttecl  line  iudi- 
cates  the  position  of  the  steel  support. 


266 


TUBERCULOUS  DISEASE  OF  THE  HIP  JOINT. 


weight  attached  to  the  foot,  to  prevent  the  tendency  to  distortion.  In 
ambulatory  treatment  this  method  has  little  to  recommend  it  except  ex- 
pediency, but  as  a  temporary  support  to  be  used  before  the  application 
of  a  suitable  brace,  the  plaster  spica  is  most  useful. 

The  plaster  of  Paris  spica  bandage  when  properly  applied,  is  an  ad- 
mirable support,  often  far  more  comfortable  to  the  patient  than  any 
splint,  and  it  is  at  times  an  indispensable  form  of  dressing.  It  is  criti- 
cised for  the  same  faults  as  the  plaster  jacket  and  it  may  receive  the 
same  defense,  that  the  most  severe  critics  have  had  the  least  experience 
in  its  use. 

Application  of  the  Plaster  Spica  Bandage. — A  plaster  bandage  to  as- 
sure support  should  fit  perfectly,  consequently  it  should  be  applied  as 
closely  as  is  possible,  directly  upon  a  layer  of  canton  flannel,  in  place 
of  the  thick  sheets  of  cotton  wadding  that  are  often  used  to  envelop 
the  body  and  the  limb ;  only  the  bony  prominences  of  the  ilium,  the 
knee  and  the  heel  require  other  protection.     The  bandage  should  cover 

Fig.  186. 


A  modification  of  the  Lorenz  hip  rest  used  at  the  Hospital  for  Ruptured  and  Crippled  in  the  applica- 
tion of  the  plaster  spica  bandage. 


the  lower  half  of  the  thorax,  and  it  should  extend  to  the  ends  of  the 
toes.  It  should  be  applied  under  slight  extension,  drawn  closely 
around  the  adductor  region  and  the  buttock,  which  should  be  entirely 
covered  and  supported.  At  this  point,  in  the  line  in  which  the  bar  of 
the  Thomas  hip  splint  runs,  a  piece  of  splint  wood  or  a  strip  of  malle- 
able steel,  long  enough  to  reach  from  the  middle  of  the  back  to  the  lower 
third  of  the  thigh,  should  be  incorporated  in  the  plaster.  (Fig.  185.)  A 
similar  piece  is  sometimes  placed  in  front  of  the  hip  and  another  beneath 
the  knee,  the  points  at  which  the  bandage  is  likely  to  break.  The 
proper  support  of  the  buttock,  consequently  of  the  hip  joint,  is  almost 
invariably  neglected  in  the  ordinary  application.  The  bandage  may 
be  applied  in  the  upright  posture  by  means  of  the  swing,  as  used  in  the 
application  of  the  plaster  jacket,  the  weight  being  supported  in  part  by 
the  sound  leg  while  the  other  is  pendant.  Or  it  may  be  applied  with 
the  patient  in  the  reclining  posture,  the  body  being  supported  by  a 


REDUCTION   OF  DEFORMITY 


267 


shoulder  rest,  and  the  pelvis  by  the  sacral  support  of  Lorenz.  The 
armsai-e  then  drawn  above  the  head  to  increase  the  capacity  of  the 
thorax,  while  the  two  legs  are  supported  by  an  assistant.     (Fig.  187.) 

In  the  more  recent  cases,  deformity  may  be  practically  reduced  at 
the  second  application  of  the  bandage,  because  of  the  relaxation  of  the 
spasm  assured  by  the  rest  and  fixation  ;  thus  it  is  particularly  useful  in 
the  treatment  of  young  children  in  the  outdoor  practice,  for  whom 
hospital  care  would  otherwise  be  required. 

Immediate  Reductiox  of  Deformity. — In  the  more  resistant 
cases  an  anesthetic  mav  be  administered.     If  the  deformity  be  due  sim- 


FiG.  18^ 


The  hip  rest  in  use.    The  patient  presents  fixed  flexiou  to  135  degrees  and  fixed  adduction 

of  35  degrees. 

ply  to  muscular  spasm  the  limb  may  be  placed  in  the  proper  position 
without  force,  but  if,  as  is  often  the  case  when  the  distortion  is  of  long 
standing,  it  is  caused  in  part  by  shortening  of  the  muscles  and  fasciae, 
a  certain  amount  of  force  may  be  required.  The  pelvis  should  be 
fixed  and  the  force  should  be  applied  as  far  as  possible  by  direct  ex- 
tension rather  than  by  leverage.  Subcutaneous  division  of  the  con- 
tracted tissues  about  the  anterior  superior  spine  and  in  the  adductor 
region,  may  be  required.  In  very  resistant  cases  the  reduction  of  de- 
formity by  this  method  should  be  divided  into  several  operations. 
Lorenz  ^  reduces  the  adduction  deformity  by  means  of  a  machine  that 

1  Lorenz,  Sammlung  Klin.  Vor.,  206,  Leipzig,  March,  1898. 


268 


TUBERCULOUS  DISEASE  OF  THE  HIP  JOINT. 


exercises  direct  traction  on  the  adducted  limb  while  the  sound  limb  is 
pushed  upward,  so  that  practically  no  leverage  is  exerted  on  the  joint. 
In  cases  in  which  the  deformity  is  accompanied  by  abscess,  or  when 
the  joint  is  surrounded  by  infiltrated  tissues  and  by  sinuses  this  treat- 
ment should  not  be  employed.  In  fact  in  certain  cases  of  this  class, 
especially  when  subluxation  is  present,  it  is  often  advisable  to  disre- 
gard the  deformity  that  cannot  be  reduced  by  traction  until  the  disease 
is  cured,  when  it  may  be  overcome  by  osteotomy  of  the  femur.  (See 
page  293.) 

The  immediate  reduction  of  deformity  by  this  method,  properly  per- 
formed, is  free  from  danger  ;  and  it  has  become  almost  the  routine  of 
practice  in  the  indoor  department  of  the  Hospital  for  Ruptured  and 
Crippled.  It  has  the  great  advantage  of  permitting  the  limb  to  be 
fixed  in  the  proper  position  during  the  stage  of  recumbency,  instead  of 
employing  this  time  for  its  gradual  reduction. 

Three  methods  of  reduction  of  deformity  have  been  described  : 

1.  By  means  of  the  traction  splint. 

2.  By  means  of  the  Thomas  brace. 

3.  By  means  of  the  plaster  bandage,  with  or  without  anaesthesia. 

A  fourth  method  is  that  by  means  of  the  weight  and  pulley.  This 
is  in  common  use  because  it  requires  no  special  apparatus. 

Fig.  188. 


Posture  of  the  limb  in  hip  disease  in  which  extension  acts  as  leverage,    p,  pulley  ; 
^v,  weight ;  /,  fulcrum. 

Eeductiox  of  Defoemity  by  the  Weight  axd  Pulley. — The 
traction  plasters  are  applied  to  the  limb  in  the  manner  already  de- 
scribed and  the  patient  is  placed  on  his  back  on  a  narrow  firm  mat- 
tress.    The  limb  is  then  raised  until  the  lumbar  vertebrae  rest  upon 

Fig.  189. 


I 


w 


Weight  extension  acting  as  leverage  in  hip  disease,    p,  pulley  ;  ic,  weight ;  /,  fulcrum. 

Marsh's  diagrams,  illustrating  the  advantage  of  traction  in  the  line  of  deformity,  in  order  to  avoid 

leverage.     {Uow.\rd  Marsh.) 


the  bed  and  it  is  then  moved  to  one  or  the  other  side,  if  lateral  distor- 
tion be  present,  until  the  level  of  the  pelvis  is  restored.  In  this  posi- 
tion the  limb  is  supported  on  a  pillow,  or  better  on  the  adjustable  tri- 


REDUCTION  OF  DEFORMITY. 


269 


angle  used  with  the  traction  hip  splint.  (Fig.  178.)  A  pulley  or  wheel 
is  then  ..attached  to  the  foot  of  the  bed  in  a  prolongation  of  the  line  of 
the  elevated  leg.  This  wheel  may  be  screwed  to  the  top  of  a  narrow 
board,  which  may  be  raised  or  lowered  on  the  foot  of  the  bed  as  required. 
To  the  buckles  on  the  plaster  traction  straps  a  stirrup  carrying  the 
cord  is  attached.  This  stirrup  is  simply  a  spreader  of  narrow  thin 
wood,  slightly  wider  than  the  foot,  provided  at  either  end  with  straps 
or  tapes,  its  purpose  being  to  prevent  direct  pressure  on  the  malleoli. 
(Fig.  193.)  By  means  of  a  weight  suspended  at  the  bottom  of  the  bed 
traction  is  made  upon  the  limb  to  the  extent  that  the  comfort  of  the 
patient  will  permit.  As  in  Buck's  system  of  extension,  the  foot  of  the 
bed  is  raised  to  increase  the  friction  of  the  body  and  thus  to  counteract 
the  traction  force,  but  in.the  treatment  of  children  this  is  inefficient  and 
counter  traction  must  be  provided.  A  simple  method  is  to  attach  two 
perineal  bands,  as  described  in  connection  with  the  traction  brace,  to 
strong  tapes  that  pass  above  and  below  the  patient's  body,  to  be  fixed 

Fio.  190. 


Extension  in  Mp  disease.    Marsh's  method  of  fixing  the  patient  in  bed  with  shoulder  straps  and  a 
long  T  splint  on  the  sound  side.      (Howard  Marsh.) 

to  the  head  of  the  bed  at  a  suitable  distance  from  one  another,  thus 
the  pelvis  is  supported  by  prolonged  perineal  bands. 

In  order  to  assure  efficient  and  constant  traction  the  patient  must  be 
prevented  from  sitting  up.  For  this  purpose  a  swathe  about  the  body, 
or  shoulder  straps  may  be  applied  and  attached  to  the  bed. 

A  convenient  appliance  is  that  of  Marsh.  "  This  consists  of  a  piece 
of  webbing,  passing  across  the  front  of  the  chest,  and  ending  in  two 
loops,  through  which  the  two  arms  are  passed,  and  through  w^hich  is 
threaded  another  piece  of  stout  webbing,  which  runs  transversely 
across  the  surface  of  the  bed  under  the  child's  shoulders,  and  is  fastened 
at  its  two  ends  to  the  sides  of  the  bedstead.  When  this  is  in  action 
the  patient's  shoulders  are  kept  flat  on  the  bed,  so  that  he  can  neither 
sit  up  nor  turn  on  his  side.  This  chest  band  does  not  cause  the  slightest 
discomfort.  It  is  not,  of  course,  fixed  tightly,  and  when  the  child 
finds  that  he  cannot  sit  up,  he  makes  no  further  attempt  to  do  so ;  and 
as  he  lies  flat  the  band  is  loose." 


270 


TUBERCULOUS  DISEASE  OF  THE  HIP  JOINT. 


It  is  better  however  to  use  some  form  of  apparatus  to  fix  the  patient 
more  thoroughly.     Marsh  uses  a  long  lateral   splint  of  thin  board 


Fig.  191. 


Traction  by  meaus  of  weight  and  pulley.     (R.  T.  Taylor.) 

reaching  from  the  axilla  to  a  point  below  the  sole  of  the  foot  where  a 
crossbar  is  attached.  To  this  the  patient's  body  and  sound  limb  are 
bandaged.     (Fig.  190.) 

Fig.  192. 


Method  of  fixing  the  patient  to  the  Bradford  frame  for  traction  in  hip  disease.     (R.  T.  Taylor.) 

A  plaster  spica  bandage  or  a  Thomas  splint  may  be  employed  on 
the  sound  side,  but  the  most  convenient  appliance  is  the  frame  of  gas 


LATERAL  TRACTION.  271 

pipe  covered  with  canvas,  that  has  been  described  in  the  chapter  on 
Pott's  d,isease.  Upon  this  frame  the  patient  can  be  fixed,  the  limb 
being  elevated  by  a  support  attached  to  the  frame  or  independent 
of  it.  (Figs.  191,  192.)  It  is  perhaps  needless  to  suggest  that  the  bed 
clothes  must  be  held  from  the  elevated  limb,  in  fact,  that  the  patient 
must  for  a  time  be  enclosed  in  a  tent  of  bed  clothes,  if  the  deformity- 
is  extreme.  At  first  the  traction  weight  must  not  be  great,  but  as  the 
perineum  becomes  accustomed  to  pressure,  as  much  weight  as  can  be 
tolerated  is  used,  from  ten  to  twenty  pounds  being  the  average.  This 
may  be  reduced  at  night  and  increased  during  the  day.  Great  care 
must  be  taken  to  prevent  painful  pressure  on  the  perineum  by  careful 
adjustment  and  frequent  inspection  of  the  perineal  bands. 

If  the  frame  is  used  it  may  be  provided  with  a  windlass  at  the  bot- 
tom for  traction  and  with  an  arched  band  of  metal  across  the  pelvis 
for  the  attachment  of  the  perineal  bands  which  behind  are  fastened  to 
the  side  bars  at  a  higher  level.  Thus  the  frame  may  be  made  an  in- 
dependent recumbent  splint  on  which  the  patient  may  be  moved  about. 
If,  however,  one  desires  to  exert  traction  to  the  point  of  distraction, 
the  weight  and  pulley  arrangement  will  often  be  required ;  in  this  case 
the  limb  should  be  placed  in  an  attitude  of  slight  flexion  and  abduction 
so  that  the  femur  may  be  drawn  more  directly  from  the  acetabulum. 

Fig.  193. 


Lateral  and  longitudinal  traction  in  hip  disease.     (Page.) 

Lateral  Traction. — Thus  far  longitudinal  traction  has  been  consid- 
ered, but  lateral  traction  or  traction  in  the  line  of  the  neck  of  the 
femur  deserves  some  consideration. 

Mr.  Thomas,  who  condemns  all  forms  of  traction  as  deceptive  and 
irrational,  and  especially  longitudinal  traction,  speaks  thus  of  lateral 
traction.  "  For  surely  if  relief  from  pressure  be  required,  the  only 
direction  in  which  this  is  possible  is  clearly  in  the  axis  of  the  neck  of 
the  femur.  Any  method  of  extension  in  the  axis  of  the  body  merely 
transfers  the  pressure  from  the  upper  part  of  the  acetabulum  to  the 


272  TUBERCULOUS  DISEASE  OF  THE  HIP  JOINT. 

lower  quarter."  ^  This  contention  is  purely  theoretical  as  there  is  no  evi- 
dence to  show  that  injurious  pressure  is  ever  exerted  upon  this  part  of  the 
acetabulum.  On  the  contrary,  the  specimens  from  subjects  who  have 
been  treated  by  longitudinal  traction  in  recumbency  and  by  means  of 
the  traction  hip  splint,  almost  invariably  show  the  effect  of  pressure 
upon  the  upper  part  of  the  head  of  the  femur  and  upon  the  upper  ad- 
joining margin  of  the  acetabulum.  Moreover,  the  neck  of  the  femur 
is  in  childhood  so  short  and  is  set  upon  the  shaft  at  so  great  an  angle, 
that  longitudinal  traction,  if  the  limb  be  slightly  abducted,  is  prac- 
tically speaking  in  the  line  of  the  neck ;  so  that  even  from  the  the- 
oretical standpoint,  the  question  of  injurious  pressure  could  only  arise 
in  the  treatment  of  adults.  The  advantages  of  lateral  traction  in  the 
treatment  of  hip  disease  have  been  urged  with  great  persistency  by  A. 
M.  Phelps,^  since  1889,  and  it  has  been  applied  as  a  routine  practice 
in  ambulatory  treatment  by  Blanchard,^  of  Chicago,  since  1872. 

The  effect  of  lateral  traction  in  recumbency  has  been  carefully  in- 
vestigated by  C.  G.  Page.*  His  conclusions  are  that  lateral  traction 
alone  is  of  no  benefit,  but  if  applied,  together  with  longitudinal  trac- 
tion, it  gives  great  relief  in  some  acute  cases.  The  longitudinal  trac- 
tion should  be  twice  as  great  as  the  lateral,  ten  and  five  pounds  being 
the  average  weights  employed  in  his  experiments.  The  method  is 
shown  in  the  illustration.     (Fig.  193.) 

The  Relative  Efficiency  of  Traction  and  Splinting  ("  Fixation  "). 

In  considering  the  vexed  question  of  the  relative  merits  of  splinting 
and  traction  in  preventing  muscular  spasm  and  the  consequent  intra- 
articular pressure  which  causes  pain  and  increases  the  destructive  ef- 
fects of  the  disease,  these  facts  must  be  borne  in  mind. 

The  more  acute  the  disease  the  less  the  ability  of  the  joint  to  carry 
out  its  proper  function,  which  is  motion.  The  greater  the  motion 
under  these  circumstances  the  more  intense  the  muscular  spasm  of 
which  the  object  is  the  prevention  of  motion.  If  it  were  possible  there- 
fore to  fix  the  joint  absolutely  there  should  be  no  muscular  spasm, 
although  the  tension  of  acute  disease  within  the  bone,  or  of  its  products 
within  the  joint,  might  cause  pain. 

When  the  patient  is  fixed  in  the  recumbent  posture  it  is  possible  to 
apply  a  sufficient  traction  upon  the  muscles  to  prevent  the  contraction 
that  causes  injurious  pressure,  and  although  no  amount  of  traction  will 
absolutely  prevent  motion,  yet  with  the  support  that  the  bed  provides, 
practically  speaking,  complete  rest  may  be  assured.  Only  in  the  excep- 
tional cases  in  which  the  tension  upon  congested  tissues  about  an  acutely 
inflamed  joint  is  intolerable  is  this  method  of  treatment  inefficient. 

The  same  statement  is  true  of  a  properly  applied  spica  bandage  or 
Thomas  brace,  when  the  patient  is  recumbent,  that  it  assures  practical 
rest ;  thus  it  prevents  muscular  contraction,  relieves  the  symptoms  and 

'Loc.  cit.,  p.  10.  ^N.  Y.  Med.  Record,  May  4,  1889. 

3  Trans.  Am.  Orth.  Ass'n,  Vol.  VII. 

<C.  G.  Page,  Bost.  Med.  and  Surg.  Journal,  Sept.  13,  1894. 


RELATIVE  EFFICIENCY  OF  TRACTION  AND  SPLINTING.     273 

promotes  repair,  although  it  cannot  be  claimed  that  the  surfaces  of  the 
opposing'  bones  are  actually  separated  from  one  another. 

But  what  is  true  when  the  patient  is  recumbent  is  not  true  of  am- 
bulatory treatment.  The  traction  exerted  by  the  hip  splint  even  when 
the  limb  is  pendant  is  far  less  eifective  than  in  recumbency,  and  when 
it  is  used  as  a  walking  appliance,  for  which  it  was  designed  and  for 
which  it  is  practically  always  employed,  the  traction  is  intermittent 
and  of  doubtful  efficiency.  The  same  loss  in  efficiency  in  less  degree 
occurs  in  all  forms  of  fixative  apparatus  when  used  in  ambulation. 

The  Removal  of  Direct  Pressure — "  Stilting." — But  granting  that  the 
traction  brace  as  a  walking  appliance  is  relatively  inefficient  in  pre- 
venting motion,  and  that  motion  without  friction,  provided  the  joint 
surfaces  are  actually  involved,  is  impossible,  still  it  cannot  be  denied 
that  the  traction  brace  is,  or  may  be,  at  all  times  an  effective  stilt  in 
that  it  protects  the  joint  from  concussion  and  pressure  by  removing  the 
foot  from  contact  with  the  ground. 

It  is  true  that  the  removal  of  direct  pressure  may  be  attained  by 
the  use  of  axillary  crutches,  but  in  Thomas'  practice,  they  were  used 
in  but  few  cases.^  In  fact  it  is  only  by  constant  supervision  that  the 
use  of  crutches  can  be  enforced  upon  children  who  no  longer  suffer  pain, 
and  as  it  is  practically  impossible  to  prevent  the  patient  from  bearing 
weight  upon  the  limb,  stilting  by  this  means  is  relatively  inefficient. 

That  direct  pressure  is  one  of  the  causes  of  upward  displacement  of 
the  femur  may  be  inferred  from  the  statistics  of  Sasse  and  Bruns,^  from 
the  surgical  clinics  of  Berlin  and  Tubingen  where  the  routine  of  treat- 
ment is  the  plaster  bandage,  without  the  high  shoe  or  crutches.  In 
two-thirds  of  Basse's  and  in  four-fifths  of  Bruns'  cases  there  was  up- 
ward displacement  of  the  trochanter.  This  is  certainly  a  larger  pro- 
portion than  would  be  found  in  a  corresponding  class  of  patients  treated 
by  efficient  stilting,  although  statistics  on  this  point  from  American 
sources  are  lacking. 

In  the  final  comparison  of  the  claims  of  traction  and  fixation,  it  is 
of  interest  to  note  that  the  most  enthusiastic  advocate  of  the  Thomas 
treatment  in  this  country,  was  trained  in  the  use  of  the  traction  hip 
brace  at  the  New  York  Orthopaedic  and  Dispensary  Hospital,  an  in- 
stitution founded  by  Taylor  and  in  which  his  methods  have  been 
closely  followed.  Ridlon  states  that  an  experience  in  the  treatment  of 
eleven  hundred  cases  by  the  traction  hip  splint,  led  him  to  discard  it 
in  favor  of  the  Thomas  brace.^ 

The  Practical  Combination  of  Traction — Splinting  and  Stilting. — 
Thus  far,  the  methods  of  treatment  by  splinting  and  traction  have 
been  presented  as  if  they  were  necessarily  opposed  to  one  another  in 
principle,  and  as  if  the  theory  were  still  held,  that  motion  without 
friction  is  possible  ;  and  as  if  it  were  believed  that  anchylosis  is  caused 

'  Ridlon,  loc.  cit. 

2 Sasse,  Arbeit  aus  der  Chir.  Klin.,  Berlin,  1896.  Bruns,  Archiv.  fiir  klin.  Chir., 
Bd.  48,  H.  1. 

3  Eidlon,  Trans.  Am.  Orth.  Ass'n,  Vol.  II. 
18 


274  TUBERCULOUS  DISEASE  OF  THE  HIP  JOINT. 

by  fixation  and  is  prevented  by  the  motion  of  a  diseased  joint.  At 
the  present  time,  however,  it  is  generally  recognized  that  the  principle 
involved  in  both  methods  is  the  same,  and  that  the  actual  merit  of 
each  must  be  decided  by  practical  experience  rather  than  by  argument. 
The  true  test  of  the  relative  value  of  a  routine  of  treatment  is  its  effi- 
cacy in  hospital  practice,  where  its  weak  points  cannot  be  supplemented 
by  the  careful  supervision  that  may  make  almost  any  treatment  that 
carries  out  in  some  degree  the  proper  principle,  effective.  This  test 
is  all  the  more  necessary  because  the  great  majority  of  cases  of  this 
character  are  to  be  found  among  the  poor. 

From  this  point  of  view  the  writer's  experience  may  be  of  interest. 
His  early  training  was  entirely  in  the  traction  method,  but  the  obser- 
vation of  a  large  number  of  cases  in  which  this  treatment  was  used, 
led  to  the  following  conclusions. 

In  one  sense  the  treatment  was  successful,  in  that  it  in  great  degree 
relieved  the  symptoms  throughout  the  greater  part  of  the  course  of  the 
disease  and  enabled  the  patients  to  go  about  in  the  open  air,  to  attend 

Fig.  194. 


The  short  spica  bandage  in  combination  with  the  brace,  cue  perineal  band  has  been  removed  in  or- 
der to  show  how  the  joint  is  supported  by  the  bandage. 

school  and  even  to  join  in  the  games  of  their  fellows.  It  was  evident 
however,  from  an  inspection  of  the  patients  as  they  returned  for  treat- 
ment, that  the  relief  of  symptoms  was  due  to  the  protection  insured  by 
the  stilting  or  crutch-like  action  of  the  brace  and  not  by  the  traction, 
which  was  usually  simply  traction  in  name,  not  in  fact.  But  if  the  brace 
relieved  symptoms,  it  did  not,  in  many  instances,  prevent  deformity ; 
and  as  the  prevention  of  deformity  is  an  object  only  secondary  in  im- 
portance to  the  relief  of  pain,  the  treatment  was  in  so  far  unsatisfac- 
tory. This  deformity  was  usually  flexion,  occasionally  combined  with 
adduction,  a  deformity  often  increasing  slowly  without  pain,  or  other 
evidence  of  greater  activity  of  disease.  If  the  deformity  were  reduced 
by  traction  in  recumbency,  it  reappeared  when  ambulatory  treatment, 
by  the  brace,  was  resumed.  This  flexion  seemed  to  be  in  many  in- 
stances simply  an  adaptation  to  the  prevailing  postures.     When,  for 


RELATIVE  EFFICIENCY  OF  TB ACTION  AND  SPLINTING.      275 


Fig.  195. 


example,  the  patient  assumed  the  sitting  position,  the  limb  was  flexed 
in  spite  of  the  brace,  and  as  much  of  the  time  was  passed  in  this  atti- 
tude, its  influence  on  the  production  of  deformity  seemed  to  be  ob- 
vious. It  was  also  apparent  that  the  brace  was  not  efl^ective  in  relieving 
pain  during  the  more  acute  exacerbations,  even  during  recumbency 
with  such  traction  as  could  be  applied  by  the  parents ;  nor  when  the 
children  were  brought  in  arms  to  the  Clinic. 

It  is  doubtless  true  that  with  proper  nursing  and  proper  care  the 
apparatus  might  have  been  efficient,  but  the  conditions  were  other- 
wise. Under  these  conditions  it  was  found  that  acute  symptoms  might 
be  relieved,  or  greatly  modified,  al- 
most at  once,  by  the  application  of 
a  close-fitting  short  spica  bandage 
extending  from  the  middle  of  the 
thorax  to  the  knee.  Over  this  the 
brace  was  applied  as  before,  making 
an  apparatus  which  then  combined 
splinting,  traction  and  stilting.  (Fig. 
194.)  This  treatment  was  repeated 
in  many  instances,  always  with  the 
same  result.  As  the  application  of 
the  plaster  bandage  was  a  some- 
what tedious  proceeding,  it  was 
often  exchanged  for  a  short  Thomas 
splint  worn  beneath  the  pelvic  band 
of  the  traction  brace  in  the  same 
manner.  This  fixation  appliance 
not  only  relieved  pain  in  the  acute 
cases,  but  it  also  prevented  the  de- 
formity, which  was  not  checked  by 
the  traction  brace  alone. 

This  combination  of  the  Thomas 
brace  and  the  traction  hip  splint, 
is  the  most  effective  mechanical 
means  of  relieving  pain  and  pre- 
venting deformity,  that  can  be  em- 
ployed in  ambulatory  treatment.  It 
has,  however,  the  disadvantage  of 
requiring  careful  adjustment,  and 
it  obliges  the  patient  to  wear  shoul- 
der straps ;  in  other  words  much 
care  must  be  exercised  to  insure  the 

comfortable  adjustment  of  both  appliances.  Thus  the  next  step  was 
the  combination  of  the  two,  even  though  the  action  was  somewhat  less 
effective.  To  the  pelvic  band  of  the  traction  brace  a  lateral  thoracic  bar 
was  attached  reaching  upward  in  the  axillary  line  to  a  point  opposite 
the  middle  of  the  scapula,  where  it  was  joined  to  a  metal  band  that  en- 
circled the  chest,  like  that  of  the  Phelps  brace.    When  this  was  securely 


The  long  inexpensive  brace  with  solid  up- 
right showing  the  perineal  bands  and  the  ad- 
hesive plaster,  as  used  in  hospital  practice. 


276 


TUBERCULOUS  DISEASE  OF  THE  HIP  JOINT. 


fastened  about  the  chest,  the  body  and  the  limb  were  held  in  line  by  a 
long  lateral  brace  ;  the  pelvis  was  supported  by  the  pelvic  band  and  the 
joint  received  the  additional  protection  that  was  assured  by  traction 
and  stilting.  ^     (Figs.  195  and  196.) 

This  brace  and  another  form  similar  in  principle,  in  which  the  up- 
right of  the  thoracic  attachment  is  fixed  posteriorly  to  the  pelvic  band, 
are  now  in  general  use  at  the  Hospital  for  Ruptured  and  Crippled, 
The  efficiency  of  this  brace  may  be  still  further  increased  by  replacing 
the  perineal  bands  by  a  metallic  ring.  This  ring,  which  fits  the  upper 
extremity  of  the  thigh  closely,  is  attached  to  the  upright  at  an  inclination 
corresponding  to  the  line  of  the  groin.  (Fig.  197.)  (The  Thomas  ring 
described  fully  in  connection  with  his  knee  splint.)  It  is  a  better  sup- 
port because  it  prevents  antero-posterior  motion  within  the  pelvic  band, 
which  the  perineal  straps  allow.  The  ring  may  be  used  as  the  only 
support  or  it  may  be  combined  with  a  perineal  band  on  the  opposite 
side.     This  is  of  advantage  if  there  is  a  tendency  toward  adduction. 

The  apparatus  is  most  satisfactory  when  the  hollow  upright  of  the 

Fig.  196. 


The  long  hip  splint  applied. 

Taylor  brace  is  used.  This  is  light  and  strong  and  is  provided  with 
an  arrangement  for  effective  traction,  but  in  hospital  practice  the  up- 
right is  made  of  solid  metal,  and  the  traction  is  adjusted  by  simple 
straps.  The  metallic  ring,  besides  providing  better  fixation,  is  a  firm 
support  that  can  not  be  disturbed  by  the  patient.  It  is  of  course  more 
difficult  of  adjustment,  and  it  is  not  suited  to  the  treatment  of  young 
children  because  of  the  difficulty  in  keeping  it  clean  and  dry. 

The  Thomas  ring  was  first  applied  to  a  hip  splint  by  Phelps.  (Fig. 
199.)  He  has  always  urged  the  advantages  of  fixation  and  traction, 
and  his  brace,  of  which  that  last  described  is  simply  a  slight  modifica- 
tion, is  supplied  with  an  arrangement  for  lateral  traction.  Practically 
speaking,  this  is  a  tape  by  which  the  lower  third  of  the  thigh  is  held 
in  apposition  to  the  upright.  It  hardly  seems  possible  that  appreciable 
lateral  traction  can  be  exerted  on  the  joint  by  this  means,  and  certainly 
none  whatever  if  the  metallic  ring  is  properly  fitted  to  the  thigh.  The 
simple  straps  do  not  afford  as  effective  traction  as  the  rack  and  pinion 

1  Eidlon  at  one  time  used  a  brace  identical  with  this  ( Trans.  Colorado  Med.  Soc. , 
1895)  but  Phelps  appears  to  have  first  described  a  form  of  brace  Avith  a  thoracic  sup- 
port in  the  axillary  line. 


RELATIVE  EFFICIENCY  OF  TRACTION  AND  SPLINTING.        277 

nor  is  the  brace,  as  usually  constructed,  sufficiently  strong  to  bear  the 
weight  of  the  body  without  bending.  It  should  be  stated,  however, 
that  this  form  of  brace  is  intended  to  be  used  with  crutches  rather 
ihan  as  a  walking  appliance. 

Many  objections  to  this  attempt  to  combine   the  two  methods  of 


Fig.  197. 


Fig.  198. 


The  long  brace  with  Thomas  ring  and  exten- 
sion upright,  similar  to  Phelps'  brace. 


Rear  view  of  brace. 


treatment  in  one  appliance  have  been  urged  by  those  who  believe  in 
the  efficiency  of  the  traction  brace.  For  example,  it  is  said  that  the 
splinting  is  ineifective  because  the  movements  of  the  trunk  are  trans- 
mitted to  the  joint,  while  this  is  not  true  of  braces  that  do  not  extend 


278 


TUBERCULOUS  DISEASE  OF  THE  HIP  JOINT. 


above  the  pelvis.  In  reply  it  may  be  stated  that  the  traction  part  of 
the  combined  splint  remains  as  effective  as  before  ;  thus  it  follows  that 
this  suggestion  is  an  acknowledgment  of  the  fact  that  the  theory  of 
motion  without  friction  is  no  longer  tenable.  As  a  matter  of  experience, 
however,  it  w^ill  be  found  that  motion  of  the  upper  part  of  the  trunk  is 
absorbed,  as  it  were,  in  the  flexible  lumbar  region  of  the  spine,  before  it 
reaches  the  joint.  If,  however,  such  motion  or  any  motion  causes  dis- 
comfort or  aggravates  the  symptoms,  the  patient  should  be  confined  in 
the  recumbent  posture  until  the  acute     '       '  ' 

phase  of  the  disease  is  passed.  Fig.  200.  j 

It  is  said  that  the  brace  is  cumber- 


Fro.  199. 


The  Phelps  hip  splint. 


A  chair  to  be  used  with  the  long 
hip  splint.  The  patient  sits  upon  the 
sound  side,  while  the  splinted  half  of 
the  body  remains  in  the  extended  po- 
sition, the  brace  resting  on  the  floor. 


some,  that  the  patient  can  not  sit  with  comfort,  and  that  it  prevents 
normal  activity. 

A  long  brace  certainly  weighs  more  than  a  short  one,  and  if  a  brace 
prevents  flexion  at  the  hip  and  spine,  it  is  evident  that  the  patient  can 
not  sit  with  comfort  in  an  ordinary  chair. 

As  a  matter  of  fact  the  patients  themselves  make  little  complaint  of 
the  brace,  even  when  it  has  been  substituted  for  an  ordinary  traction 
splint ;  while  the  greater  restraint  of  activity  is  a  favorable  element  of 
treatment,  since  children  who  do  not  suffer  pain  are  much  more  likely 
to  be  too  active  than  to  be  restrained  by  any  form  of  appliance.  These 
objections  are  trivial,  if  one  is  convinced  that  the  dangerous  and  de- 


RELATIVE  EFFICIENCY  OF  TRACTION  AND  SPLINTING.     279 


forming  disease  that  is  under  treatment  may  be  more  easily  controlled 
and  that  the  final  result  is  likely  to  be  better  and  to  be  more  rapidly 
attained  by  this  means  than  by  another. 

This  form  of  brace  is  used  exactly  as  is  the  ordinary  traction  brace. 
If  deformity  be  present  it  is  reduced  by  one  or  another  of  the  methods 


Fig.  201. 


Fig.  202. 


The  Taylor  hip  splint  as 
used  by  Taylor  in  the  later 
years  of  his  practice  with 
but  one  perineal  band. 

The  cut  shows  also  an 
appliance  for  preventing  or 
for  correcting  slight  degrees 
of  adduction,  while  the 
brace  is  in  use  as  a  walking 
appliance.  The  abduction 
bar  is  buckled  about  the 
upper  extremity  of  the  other 
thigh.  (H.  L.  Taylor,  Med. 
News,  March  23,  1889.) 


Taylor's  median  abduction  brace  used  as  a  bed  splint  to  overcome 
adduction  by  counter-pressure  on  the  sound  side. 


that  have  been  described.     If  the  disease  be  acute,  recumbency  and 
traction  are  employed  until  this  stage  is  passed. 

When  ambulation  is  resumed  crutches  may  be  employed  for  a  time, 
but  during  the  greater  part  of  the  treatment  the  brace  is  used  as  a 
walking  appliance  ;  as  accurate  splinting  and  as  effective  traction  being 
employed  during  this  period  as  circumstances  will  permit. 


280 


TUBERCULOUS  DISEASE  OF  THE  HIP  JOINT. 


Fio.  203. 


During  the  entire  course  of  treatment,  supervision  of  the  patient, 
with  the  aim  of  adapting  his  activity  to  the  local  weakness,  should  be 
exercised,  even  though  it  may  be  less  essential  than  when  other  appa- 
ratus is  employed. 

The  impression  that  one  might  receive 
from  descriptions  of  the  treatment  of  hip 
disease,  is  that  most  cases  begin  acutely, 
or  that  when  the  patients  are  brought  for 
treatment  the  disease  is  in  an  acute  stage, 
or  that  deformity  is  present,  so  that  pre- 
liminary recumbency  is  required.     But 
each  year  the  proportion  of  early  cases  is 
greater,  cases  in  which  there  is  no  defor- 
mity and  in  which  acute  symptoms  are 
absent.     In  such  instan- 
FiG.  204.        ces  the  hip  splint  may  be 
applied  without  prelimi- 
nary recumbency,  and  if 
the  joint  is  fixed  in  the 
normal  attitude  and  pro- 
tected, a  relatively  rapid 
recovery   without   defor- 
mity and  with  a  fair  range 
of  motion  may  be  hoped 
for. 

The  Treatment  of  Hip 
Disease  During  tlie  Stage 
of  Recovery. — It  is  much 
easier  to  assure  oneself 
that  the  disease  is  still 
active  than  to  decide 
when  it  is  cured.  For 
the  symptoms  may  have 
been  quiescent  for 
months  or  years  even, 
under  the  protective 
treatment,  and  yet  they 
may  recur  on  the  slight- 
est provocation  when  this 
treatment  has  been  dis- 
continued. 

To  judge  of  the  prob- 
able duration  of  the  dis- 
ease in  a  given  case,  one 
must  consider  its  area,  its  quality  and  its  complications.  If,  for  example, 
the  primary  symptoms  indicate  that  it  is  a  limited  focus  of  infection 
contained  within  the  bone,  rapid  recovery,  possibly  in  a  year,  may 
be  expected  ;  but  in  the  ordinary  type  of  disease  in  which   the  joint 


^Modified  brace  to  be  worn  during 
convalescence.  Same  patient  as  in 
Fig.  198.  Tlie  thoracic  part  iias  been 
removed  and  the  lower  end  of  the 
stem  has  been  made  into  a  caliper, 
passing  through  the  heel  of  tlie  shoe. 
The  stem  is  extended  by  means  of  the 
key  until  the  heel  is  lifted  slightly 
from  the  shoe,  thus  the  hip  is  relieved 
from  shock. 


Judson's  perineal 
crutch.  This  support 
suspended  from  the 
shoulders  may  be 
employed  as  a  sub- 
stitute for  axillary 
crutches.  It  is  also 
used  as  a  convales- 
cent splint  in  the 
treatment  of  hip  dis- 
ease. 


TBEA TMENT  DURING  CON VA LESCENCE  IN  HIP  DISEASE.      281 


Fig.  205. 


has  been  invaded,  repair  can  hardly  be  anticipated  in  less  than  three 
or  foul^  years. 

•  Supposing  the  time  to  have  elapsed  in  which  a  natural  cure  may 
have  been  accomplished  ;  if  the  patient  has  had  no  symptoms  of  disease 
for  a  year  or  more  ;  if  there  are  no  local  signs  of  active  disease,  and 
if  muscular  spasm  is  absent,  one  may  test  the  joint  by  removing  the 
brace  at  night  to  ascertain  the  effect  of  simple  motion  without  weight 
bearing.  Such  freedom  will  enable  the  patient  to  move  the  knee, 
which  having  been  fixed  in  the  extended  position  for  so  long  usually 

remains  stiff  for  a  time,  and  in  many  in- 
stances several  months  may  elapse  before 
the  full  range  of  motion  is  regained. 

It  is  well  also  to  remove  the  thoracic  part 
of  the  brace,  to  allow  the  patient  more  mo- 
bility at  the  hip.  At  a  later  time  the  trac- 
tion may  be  discontinued  and  the  brace  may 
be  suspended  from  the  shoulders  to  serve  as  a 
perineal  crutch  (Fig.  204);  or  it  may  be  at- 
tached to  the  shoe  and  so  adjusted  as  to  be 
slightly  longer  than  the  limb,  in  order  that 
direct  concussion  and  pressure  may  be  les- 
sened. (Fig.  203.)  Or  a  brace  jointed  at  the 
knee,  after  the  Taylor  pattern  may  be  em- 
ployed. 

This  brace  is  so  adjusted 
as  to  be  slightly  longer  than 
the  leg,  so  that  the  heel  does 
not  touch  the  bottom  of  the 
shoe.  (Fig.  206.)  Thus  the 
weight  is  in  great  part  sup- 
ported on  the  perineal  band. 
The  weight  of  the  brace  may 
be  in  part  supported  and 
incidentally  slight  traction 
may  be  exerted  by  adhesive 
plaster  applied  above  the 
knee.  (Fig.  207.)  The  foot 
plate  to  which  the  upright 
is  attached  is  shown  in  Figs. 
206  and  208. 

As  the  strain  upon  the 
part  is  increased,  one 
watches  carefully  for  the 
return  of  muscular  spasm 
or  for  restriction  of  the  range  of  motion.  If  the  range  of  motion  does 
not  diminish,  and  if  the  deformity  that  may  be  present  does  not  in- 
crease or  does  not  appear  if  it  be  absent,  the  brace  may  be  removed  at 
intervals  and  finally  discarded. 


Fig.  206. 


Convalescent  hip  spliut,  allowing  motion  at  the  knee. 
(Taylor.) 


282 


TUBERCULOUS  DISEASE  OF  THE  HIP  JOINT. 


This  stage  of  supervision  even  in  favorable  cases  should  be  protracted, 
for  no  patient  can  be  considered  free  from  the  danger  of  relapse  for  a 
long  time  after  apparent  cure.  If  there  be  firm  bony  anchylosis,  as  in. 
exceptional  cases,  cure  is  assured  ;  but  if  there  be  simply  fibrous  anchy- 
losis, and  particularly  if  there  be  upward  displacement  of  the  trochanter, 
a  tendency  to  deformity  remains,  particularly  toward  flexion  and  ad- 
duction, even  though  the  disease  is  cured.     In  such  cases  it  is  often 


Fig.  207. 


Fig.  208. 


Fig.  209. 


^\ 


.<-m 


Details  of  the  Taylor  convalescent  hip  brace.  Fig. 
207,  the  adhesive  plaster.  J'ig.  208,  the  foot  plate  show- 
ing the  method  of  attachment. 


The  action  of  the  Taylor  convales- 
cent hip  brace  in  removing  direct 
pressure  illustrated  by  a  wooden 
model. 


necessary  to  employ  apparatus  at  intervals  to  reduce  the  deformity  or  to 
hold  the  limb  in  proper  position  until  stability  is  assured.  When  the 
brace  has  been  discarded,  the  patient  should  be  trained  to  walk  with 
equal  steps,  placing  the  limb,  as  far  as  is  possible,  on  an  equality  with 
its  fellow  and  adapting  in  like  manner  the  stronger  to  the  weaker 
member.    This  has  an  important  influence  in  checking  the  tendency  to 


DOUBLE  HIP  DISEASE. 


283 


deformity  and  in  modifying,  or  even  concealing,  the  limp,  a  point  to 
which  Judson  has  repeatedly  called  attention. 


Fig.  210. 


Double  hip  disease  terminating  in  bony  anchylosis.  ; 

Double  Hip  Disease. 

Ninety-five  cases  of  bilateral  hip  disease  were  treated  in  the  Hospital 
for  Ruptured  and  Crippled  during  the  ten  years  ending  in  1899. 

As  a  rule  the  second  hip  is  affected  some  time  after  the  symptoms  of 
disease  of  the  first  have  been  apparent,  but  occasionally  both  joints  are 


Fig.  211. 


f  Left  hip  disease,  showing  swelling  caused  by  abscess,  also  the  absence  of  flexion  defoimity. 


284 


TUBERCULOUS  DISEASE  OF  THE  HIP  JOINT. 


involved  simultaneously.  In  most  instances  the  symptoms  are  rather 
subacute,  owing,  very  likely,  to  the  fact  that  the  activity  of  the  patient 
is  so  restricted. 

Treatment. — The  treatment  is  similar  in  principle  to  that  of  the 
unilateral  form.  The  patient  during  the  greater  part  of  the  course  of 
the  disease  must  be  confined  in  the  recumbent  position,  although  not 

necessarily    in     bed.      The    double 
Fig.  212.  Thomas    hip  splint   is   a  convenient 

means  of  fixation.  With  this  appa- 
ratus, extension  by  means  of  the 
weight  and  pulley  may  be  employed, 
or  the  brace  may  be  so  modified  as  to 
provide  independent  traction.  If  the 
disease  of  one  hip  is  acute  and  is  at- 
tended by  abscess  formation,  excision 
for  the  purpose  of  lessening  the  strain 
upon  the  patient  and  assuring  a  cer- 
tain amount  of  motion  in  one  limb 
may  be  advisable. 

If  motion  is  greatly  restricted  in 
both  joints  locomotion  unless 
crutches  are  used,  is  very  difficult,  as 
motion  at  the  knees  can  supply  onh- 
in  small  part  the  function  of  the  hip 
ioints. 


Hip  Disease  Combined  with  Disease 
of  Other  Parts. 

The  most  common  combination  is 
with  Pott's  disease.  The  two  may  be 
distinct  primary  foci,  but  occasionally 
it  would  appear  that  the  disease  of  the 
hip  is  caused  by  the  infection  of  an 
abscess,  which,  coming  from  the  spine, 
remains  for  a  long  time  in  contact  with 
the  capsule  of  the  joint.  In  five  of  the 
one  hundred  and  fifty  cases  of  disease 
of  the  hip  joint  of  which  the  final  re- 
sults are  reported  by  Gibney,  Water- 
man and  Reynolds  (page  298),  Pott's 
disease  was  a  complication  ;  in  two 
instances  preceding,  and  in  three  fol- 
The  combination  of  the  two  diseases 
Recumbency   offers  the 


Untreated  hip  disease.  Slight  flexion 
and  adduction  (apparent  shortening). 
The  scar  of  a  former  abscess  is  seen  on 
the  outer  aspect  of  the  thigh. 


lowing,  the  disease  at  the  hip 

makes   the  mechanical   treatment  difficult 

best  opportunity  for  the  effective  adjustment  of  apparatus  when  the 

disease  of  either  part  is  acute.     At  a  later  period  crutches  may  be 

employed,  together  with  the  necessary  braces. 


HIP  DISEASE  IN  THE  ADULT.  285 

Hip  Disease  in  Infancy. 

Hip  disease  in  infancy  is  far  less  common  than  in  early  childhood. 
It  presents  nothing  of  especial  interest  except  that  its  effect  upon  the 
function  of  the  joint  and  upon  the  development  of  the  limb  is  usually 
more  marked  than  in  older  subjects.  (Fig.  184.)  Tuberculous  disease 
of  this  joint  must  be  differentiated  from  infectious  epiphysitis,  in 
which  prompt  operative  treatment  is  indicated. 

Hip  Disease  in  the  Adult. 

Hip  disease  in  the  adult  may  present  the  typical  symptoms  of  the 
ordinary  form,  but  it  is  usually  of  the  more  subacute  type.  Not  infre- 
quently it  is  a  complication  of  tuberculosis  of  the  lungs.  The  mechan- 
ical treatment  is  not  difficult,  but,  in  many  instances,  early  excision  may 
be  advisable  in  order  to  bring  about  a  rapid  cnre  of  the  disease.  This 
is  far  more  important  than  in  childhood,  because  few  adults  can  afford 
the  time  required  for  the  natural  cure,  and  because  in  many  instances, 
the  general  condition  of  the  patient  may  demand  relief  from  the  de- 
pressing effects  of  the  local  disease,  especially  if  it  be  complicated  by 
suppuration. 

The  subacute  form  of  tuberculous  disease  is  often  difficult  to  dis- 
tinguish from  arthritis  deformans,  if  this  be  confined  to  the  hip  joint. 

Abscess  in  Hip  Disease. 

It  may  be  assumed  that  a  limited  collection  of  fluid  product  of  the 
tuberculous  process  is  present  in  nearly  every  case  of  hip  disease  in 
which  the  joint  surfaces  are  actually  involved.  In  many  instances  it 
remains  within  the  joint.  In  a  larger  proportion  of  the  cases  the  cap- 
sule is  perforated,  the  fluid  escapes  and,  if  the  quantity  is  sufficient  to 
form  an  appreciable  tumor,  it  is  classed  as  an  abscess.  Such  abscesses 
may  be  detected  in  about  50  per  cent,  of  the  cases  that  are  treated 
under  ordinary  conditions. 

In  eight  hundred  and  two  final  results  collected  from  various  sources, 
the  percentage  of  abscess  was  as  appears  in  the  following  table  : 

39  cases  reported  by  Shaffer  and  Lovetti 69  per  cent. 

82  cases  reported  by  Gibney  2 60        " 

390  cases  reported  by  Bruns, 3  Tubingen 58  3     "    . 

125  cases  reported  by  Sasse,^  Berlin 50         " 

82  cases  reported  by  Preudlsberger,-5  Vienna.. 51         " 

84  cases  in  private  practice,  C.  F.  Taylor 6 25         " 

Most  often  the  abscess  first  appears  upon  the  outer  and  upper  part  of 
the  thigh,  in  the  space  between  the  sartorius  and  tensor  vaginae  femoris 

IN.  Y.  Med.  Journal,  May  21,  1887. 
2N.  Y.  Med.  Eecord,  March  2,  1878. 
3  Beit,  zurklin.  Chir.,  Bd.  30,  1895. 

<  Arbeit  aus  der  Chir.  Klinik  der  K.  Univ.  Berlin  (Bergmann's  Clinic),  1896. 
5  Behand  der  Gelenktuberculose  und  ihre  Endresultate  aus  der  Klinik  Albert,  Wien, 
1894. 

« Boston  Med.  and  Surg.  Jour.,  March  6,  1879. 


286 


TUBERCULOUS  DISEASE  OF  THE  HIP  JOINT. 


muscles.  From  this  point  it  may  find  its  way  to  the  inner  or  to  the 
posterior  surface  of  the  limb,  and  if  it  increases  in  size  it  gradually 
sinks  downward,  guided  somewhat  in  its  direction  by  the  layers  of 
fascia  that  separate  the  muscles.  In  other  instances  it  may  be  de- 
tected first  on  the  inner  side  of  the  thigh,  or  it  may  form  a  tumor  be- 
neath the  gluteal  muscles ;  its  situation  being  influenced  by  the  point 
at  which  the  capsule  is  ruptured.  In  rare  instances,  the  acetabulum 
may  be  perforated  and  a  pelvic  abscess  may  be  formed,  or  the  pus  may 
find  its  way  into  the  pelvis  along  the  course  of  the  ilio-psoas  muscle  ; 
and  occasionally  a  pelvic  abscess  may  exist  which  appears  to  have  no 
direct  communication  with  the  joint. 

The  tuberculous  abscess  is  a  symptom  and  common  accompaniment 
of  hip  disease,  which,  in  cases  treated  under  proper  conditions,  is  not  of 
great  importance  ;  and  yet  on  the  other  hand,  it  is  recognized  as  a  dan- 
gerous complication.  It  is  dangerous  to  life  because  of  the  profuse 
suppuration  that  may  follow  infection,  and  to  function  because  of  the 

Fig.  213. 


Abscess  in  hip  disease.    The  brace  is  provided  with  the  Thomas  ring  and  with  tlie  ratchet  extension. 

adhesions  and  contractions  that  may  result.  This  is  evident  in  all 
statistics.  It  is  clearly  shown  in  those  of  Bruns.  In  this  list  the 
mortality  in  the  non-suppurative  cases  was  23  per  cent,  and  of  the 
suppurative  52  per  cent. 

The  Significance  of  Abscess. — If  abscess  appears  early  in  the  course 
of  the  disease,  it  usually  indicates  that  it  is  of  a  destructive  character 
and  that  the  interior  of  the  joint  is  involved,  therefore  perfect  function 
is  less  likely  to  be  preserved  than  in  those  cases  in  which  the  disease 
has  been  confined  to  the  interior  of  the  bone. 

In  certain  instances  abscess  formation  is  preceded  by  an  acute  ex- 
acerbation of  symptoms,  by  pain,  by  an  increase  of  muscular  spasm 
and  consequent  distortion,  and  often  by  an  elevation  of  temperature. 
These  acute  symptoms  subside  and  a  fluctuating  swelling  appears.  It 
may  be  inferred  that  the  pain  in  such  a  case  was  due  to  the  tension  of 
the  abscess  within  the  capsule,  and  that  the  relief  of  pain  followed 
perforation  and  the  escape  of  the  fluid. 


TREATMENT  OF  ABSCESS.  287 

la  perhaps  the  larger  proportion  of  cases,  more  especially  those  in 
which  the  joint  has  been  protected,  the  formation  of  the  abscess  is 
not  preceded  by  acute  symptoms,  such  as  have  been  described.  Its 
appearance  is  long  delayed,  and  but  for  the  swelling  that  is  apparent, 
its  presence  would  not  have  been  suspected. 

As  the  progress  of  the  disease  is  influenced  by  the  strain  and  in- 
jury to  which  the  part  is  subjected,  so  abscess,  a  symptom  of  disease, 
is  more  common  in  those  cases  in  which  early  and  efficient  treatment 
has  been  neglected  ;  for  the  same  reason  its  subsequent  course  is  directly 
influenced  by  the  protection  that  the  diseased  joint  receives. 

The  danger  from  abscess  is,  of  course,  infection.  Occasionally  the 
abscess  may  become  infected  before  an  opening  forms.  Such  infection 
may  be  inferred  when  the  tissues  about  the  abscess  are  hot  and  sensi- 
tive, and  when  fever  is  present ;  but  as  a  rule,  the  abscess  is  sterile 
until  the  skin  is  perforated.  When  an  opening  forms  there  is  danger 
of  infection  with  pyogenic  germs.  If  the  abscess  sac  is  small  and  if 
drainage  is  efficient,  and  especially  if  the  communication  with  the  joint 
has  been  occluded,  infection  is  of  slight  consequence.  But  if  before 
the  opening  has  formed  the  abscess  has  perforated  inter-muscular  fas- 
cia and  has  extended  between  the  layers  of  muscles  in  various  direc- 
tions, the  infection  of  this  area  is  likely  to  cause  severe  local  and  con- 
stitutional symptoms.  The  thigh  becomes  the  seat  of  an  infectious 
cellulitis,  pockets  of  pus  form,  which  cannot  be  properly  drained  ; 
hectic,  emaciation  and  loss  of  appetite  follow,  and  if  the  profuse  dis- 
charge of  pus  persists,  amyloid  degeneration  of  the  internal  organs  may 
result.  Such  patients  are  said  to  die  of  exhaustion,  but  the  cause  of 
the  exhaustion  is  an  infected  abscess.  At  this  stage  the  operation  of 
excision  of  the  joint  is  often  performed.  This  operation  removes  the 
original  source  of  the  trouble,  but  the  success  of  the  procedure  depends, 
in  most  instances,  upon  the  efficiency  of  the  drainage  that  is  assured  by 
the  wide,  deep  incision  and  by  the  removal  of  the  obstructing  head  of  the 
bone.  Thus  when  suppuration  persists  after  excision  and  when  the  con- 
dition of  the  patient  is  not  improved,  amputation  is  logically  indicated. 

Treatment. — Admitting  that  abscess  is  a  symptom  whose  importance 
stands  in  direct  relation  to  the  care  that  has  been  exercised  in  the  treat- 
ment of  the  disease,  and  that  in  the  better  class  of  cases  the  danger  from 
this  source  is  slight,  still  it  is  also  true  that  abscess  is  the  chief  cause  of 
danger,  and  almost  the  only  cause  of  death,  in  hip  disease  per-  se.  One's 
views  as  to  treatment  are  likely  to  be  influenced  by  the  class  of  cases 
with  which  he  is  most  familiar.  Some  surgeons  have  advocated  abso- 
lute non-interference  with  the  symptomatic  abscess  on  the  ground  that 
in  many  instances  it  finally  disappears  by  spontaneous  absorption  ; 
while  in  other  cases  the  long  delay  allows  the  communication  with  the 
joint  to  close,  so  that  the  danger  of  infection  after  an  opening  has 
formed,  is  slight.  Finally,  that  the  results  after  non-interference  are 
better  than  those  reported  after  operative  treatment.  Others  insist 
that  all  collections  of  fluid  of  this  character  should  be  evacuated  when 
they  are  discovered,  because  of  the  danger  of  infection  before  an  open- 


288  TUBERCULOUS  DISEASE  OF  THE  HIP  JOINT. 

ing  forms  and  because  of  the  advantage  gained  by  preventing  burrow- 
ing of  pus.  There  would  be  little  to  be  said  against  this  latter  course 
were  it  not  that  infection  is  as  common  after  operative  treatment  as 
when  a  spontaneous  opening  forms ;  the  only  advantage  in  favor  of 
the  artificial  opening  being  that  the  cavity  with  which  it  communicates 
should  be  smaller  than  when  the  incision  has  been  long  delayed ;  but 
this  is  offset  by  the  fact  that  at  least  20  per  cent,  of  abscesses  disap- 
pear without  treatment.  In  fact,  as  compared  with  indiscriminate 
incisions,  when  proper  precaution  and  care  cannot  be  assured,  the  let- 
alone  treatment  should  be  preferred. 

It  would  appear,  however,  that  the  middle  course,  between  the  ex- 
tremes, is  the  safest,  and  especially  so  as  by  far  the  larger  number  of 
patients  must  be  treated  under  conditions  that  do  not  permit  of  proper 
care.  In  the  outdoor  department  of  the  Hospital  for  Ruptured  and 
Crippled  abscesses  are  treated  symptomatically.  If  a  swelling  appears 
but  remains  quiescent  and  causes  no  symptoms,  it  is  not  disturbed.  If 
it  enlarges,  the  tension  of  the  fluid  is  relieved  by  aspiration,  which 
may  be  repeated  as  required,  compression,  after  the  evacuation  of  the 
fluid,  being  applied  by  a  pad  and  bandage.  If  the  abscess  is  on  the 
point  of  finding  a  spontaneous  opening,  or  if  its  contents  are  of  such  a 
nature  that  aspiration  is  impossible,  an  incision  is  made  and  the  proper 
dressings  are  applied ;  or,  if  the  child  lives  at  a  distance  from  the  hos- 
pital, the  mother  is  instructed  in  the  manner  of  dressing  and  as  to  the 
importance  of  cleanliness. 

If  the  abscess  is  of  large  size,  or  if  acute  symptoms  are  present,  the 
child  is  admitted  to  the  hospital.  Here  the  same  general  principle  is 
followed,  but  at  the  present  time  the  routine  of  treatment  of  non-in- 
fected abscess  is  free  incision,  that  will  allow  complete  evacuation  of 
its  contents.  The  abscess  membrane  is  removed  by  gently  rubbing 
with  iodoformized  gauze.  If  the  opening  in  the  capsule  of  the  joint  is 
exposed,  this  may  be  enlarged  to  permit  of  the  evacuation  of  the  prod- 
ucts of  disease  within  the  joint,  the  wound  is  then  closed  with  super- 
ficial and  deep  sutures,  and  a  firm  dressing  is  applied.  This  operation, 
if  performed  under  aseptic  precautions,  causes  no  disturbance  and  it 
relieves  nature  from  the  burden  of  necrotic  material  which  must  be  an 
obstacle  to  spontaneous  absorption.  In  many  instances  the  abscess  is 
permanently  cured,  although  if  the  condition  that  induced  the  ab- 
scess remains  unchanged,  fluid  will  again  accumulate,  and  if  so  a  spon- 
taneous opening  will  form  at  the  site  of  the  operation.  This  operation 
is  not  a  radical  cure  of  the  abscess  or  of  the  disease,  it  is  simply  a 
means  of  thorough  evacuation  for  the  purpose  of  accomplishing  what 
the  aspirator  does  only  in  part.  If  the  abscess  has  become  infected, 
its  contents  are  completely  removed,  the  wound  is  then  packed  with 
gauze  and  provision  is  made  for  efficient  drainage. 

In  the  treatment  of  abscesses  the  injection  of  iodoform  emulsion,  in 
connection  with  the  aspiration,  has  been  thoroughly  tested.  The  re- 
sults, as  far  as  the  disappearance  of  the  abscess  was  concerned,  were 
not  as  good  as  from  simple  aspiration  ;  and  as  the  procedure,  being 


EXPLORATORY  OPERATIONS.  289 

somewhat  of  the  nature  of  an  operation,  caused  the  patients  some  dis- 
comfort and  anxiety,  it  was  discontinued.  From  the  clinical  stand- 
point there  is  little  evidence  that  these  injections  exercise  any  particular 
influence  upon  the  disease,  but  theoretically,  iodoform  should  lessen 
the  infectiousness  of  the  tuberculous  fluid,  and  there  appears  to  be  no 
serious  objection  to  its  use. 

The  Treatment  of  Sinuses. — When  the  disease  is  in  the  active 
stage  the  sinuses  that  serve  as  drains  should  not  be  interfered  with. 
And  in  the  advanced  cases  when  the  disease  is  quiescent  and  when  the 
tissues  about  the  joint  are  of  the  peculiar,  resistant,  "  porky  "  con- 
sistency, active  measures,  either  for  the  purpose  of  closing  sinuses,  or 
for  the  correction  of  deformity,  should  be  deferred.  In  many  in- 
stances, however,  sinuses  persist  as  tuberculous  fistulse,  serving  no  use- 
ful purpose.  In  this  class  the  complete  removal  of  the  infected  tissue 
by  excision,  or  by  thorough  curetting,  is  the  most  effective  remedy. 
The  various  applications  of  pure  carbolic  acid,  solution  of  salicylic 
acid,  iodoform  emulsion,  balsam  of  Peru  and  the  like,  are  of  some  ser- 
vice, but  thorough  removal  of  the  disease  is  the  only  radical  treatment. 

Exploratory  Operations. — In  certain  instances  exploratory  opera- 
tions may  be  indicated.  When,  for  example,  the  pain  and  swelling  in- 
dicate tension  within  the  capsule,  this  may  be  relieved  by  an  incision 
and  the  joint  may  be  explored  with  the  possibility  of  finding  a  local- 
ized focus  of  disease  that  may  be  removed. 

The  joint  may  be  exposed  by  an  antero-lateral  incision,  beginning 
one  inch  to  the  outer  side  of  the  anterior  superior  spine  and  extending 
downward  about  three  inches.  This  exposes  the  line  of  junction  be- 
tween the  tensor  vaginae  femoris  and  the  gluteus  medius  muscles. 
When  these  are  separated  from  one  another  the  anterior  surface  of  the 
capsule  of  the  joint  is  exposed.  If  more  room  is  required  the  tensor 
vaginae  femoris  muscle  may  be  divided.  The  capsule  is  then  incised 
in  the  line  of  the  neck  and  through  the  incision  the  head  of  the  bone 
may  be  extruded  by  rotating  the  limb  outward  and  extending  it.  By 
this  means  the  character  of  the  disease  may  be  ascertained  and  in  cer- 
tain instances  localized  foci  in  the  neck  or  in  the  head  of  the  bone  may 
be  removed.  Thus  the  course  of  the  disease  may  be  shortened  and 
cure  even  may  be  accomplished,  as  in  two  cases  reported  by  Blood- 
good.^     Such  an  outcome  is  however  most  unusual. 

Exploratory  operations  of  this  nature  may  be  of  especial  value  in 
the  later  stages  of  the  disease,  to  ascertain  the  cause  of  long-continued 
suppuration,  or  of  abnormal  delay  in  repair,  which  may  be  due  to  de- 
tached or  adherent  fragments  of  necrosed  bone  within  the  joint.  This 
point  is  illustrated  by  the  statistics  of  sixty-one  cases  of  hip  disease 
treated  by  excision,  by  Poor.^  In  fifteen  of  these,  loose  bone  was  found 
in  the  joint,  and  in  seven  the  head  of  the  bone  was  detached. 

In  ninety-eight  cases  investigated  by  Lehman  ^  at  the  Wiirzburg 

'  Bulletin  Johns  Hopkins  Hospital,  January,  1900. 
^N.  Y.  Med.  Jour.,  April  23,  1892. 
^  Inaug.  diss.  Wiirzburg,  1896. 

19 


290  TUBERCULOUS  DISEASE  OF  THE  HIP  JOINT. 

clinic,  sequestra  were  present  in  20.4  per  cent,  and  in  70  per  cent,  of 
eighty-eight  cases  treated  by  Riedel.^ 

An  exploration  of  the  joint  by  one  familiar  with  surgical  technique, 
should  be  free  from  danger.  The  wound  may  be  closed  or  it  may  be 
drained,  according  to  the  indications.  The  operation  is  not  indicated 
as  a  routine  of  practice,  nor  should  it  be  expected  by  this  means  to  cut 
short  the  course  of  the  disease,  but  in  certain  instances  it  may  be  of 
great  value. 

Excision  of  the  Hip. — At  the  Hospital  for  Ruptured  and  Crippled, 
the  operation  of  excision  is  classed  as  a  treatment  of  necessity  in  certain 
cases,  usually  those  in  which  recovery  under  conservative  treatment 
is  considered  very  doubtful.  For  example,  when  there  is  progressive 
failure  in  health ;  when  it  is  impossible  to  drain  the  joint  effectively 
after  infection  ;  when  there  is  evidence  of  extension  of  the  disease  to 
the  shaft  of  the  femur  or  to  the  pelvic  cavity,  or  when  other  serious 
complications  exist. 

In  certain  instances  the  excision  may  follow  an  exploratory  opera- 
tion ;  in  such  cases  the  antero-lateral  incision  may  be  employed  and 
the  neck  and  head  of  the  bone  only  may  be  removed.  But  in  typical 
cases  the  operation  is  performed  because  of  extensive  disease  and  in- 
fected abscess,  and  in  such  instances  the  entire  upper  extremity  of  the 
bone  to  the  trochanter  minor  is  removed,  ordinarily  by  a  posterior 
incision,  similar  to  that  of  Sayre.  The  knife  entered  above  and  in 
front  of  the  trochanter  is  carried  through  the  tissues  close  to  its  upper 
margin  and  the  incision  is  prolonged  down  the  posterior  border  of 
the  femur  to  the  trochanter  minor.  In  certain  instances  an  attempt  is 
made  to  preserve  the  periosteum  and  the  muscular  attachments,  but  in 
the  majority  of  the  advanced  cases,  the  soft  parts  are  cut  away  as 
quickly  as  possible  and  the  femur  is  divided  with  a  chisel  at  the  level 
of  the  trochanter  minor.  As  much  of  the  diseased  tissue  as  is  possible 
is  cut  away  and  the  wound,  together  with  the  connecting  suppurating 
tracts  is  packed  with  gauze.  If  the  shaft  of  the  femur  is  diseased  its 
contents  are  removed  and  a  counter  opening  for  drainage  is  made.  The 
operation  is  performed  as  quickly  as  possible  and  a  very  small  amount 
of  ansesthetic  in  employed,  nitrous  oxide  gas  having  been  used  in  many 
instances.  The  limb  is  supported  by  a  plaster  bandage  or  Thomas  brace, 
and  afterwards  a  hip  splint  is  used  for  a  time  to  prevent  deformity. 

The  functional  results  after  excision  in  this  class  of  cases  are  not  as 
good  as  those  that  are  obtained  when  the  operation  has  been  performed 
at  an  earlier  stage.  If  motion  continues  free,  the  joint  is  usually  in- 
secure. In  many  instances  there  is  upward  displacement  of  the  shaft 
of  the  femur  upon  the  ilium  with  consequent  flexion  and  adduction  de- 
formity, while  in  a  third  class  of  cases  a  movable  joint  of  sufficient 
strength  may  be  preserved.  The  ultimate  shortening  is  considerably 
greater  than  after  conservative  treatment.  This  is  accounted  for  by 
the  upward  displacement  of  the  femur  and  by  the  removal  of  the  two 
epiphyses  of  its  upper  extremity. 

iCentb.  f.  Chir.,  1893,  Bd.  XX.,  Nos.  7  and  8. 


EXCISION  OF  THE  HIP.  291 

In  the  twelve  years,  1888  to  1899  inclusive,  149  operations  of  ex- 
cision were  performed  at  the  Hospital  for  Ruptured  and  Crippled. 
During  this  time  1,283  cases  of  hip  disease  were  treated  in  the  wards 
and  1,870  new  cases  were  recorded  in  the  out-patient  department. 
Thus  the  operation  was  performed  in  11.6  per  cent,  of  those  in  the 
hospital,  but  the  relative  frequency  of  the  operation  in  the  entire  num- 
ber of  patients  under  treatment,  was  considerably  less  than  this. 

One  hundred  and  twenty-one  of  these  operations  of  excision,  or  those 
performed  prior  to  1897,  have  been  carefully  analyzed  by  Townsend.^ 
The  121  operations  were  performed  on  119  patients,  in  two  instances 
both  hips  having  been  operated  upon.  In  113,  abscesses  or  sinuses 
were  present,  in  most  instances  infected.  In  5  cases  the  spine  was  in- 
volved as  well  as  the  hip ;  in  2  instances  the  knee,  in  2  the  tarsus,  in  3 
the  ilium.  In  24  cases  the  anterior  incision  was  employed,  in  97  the 
posterior.  In  18  instances  the  acetabulum  was  seriously  diseased  and 
in  10  osteomyelitis  of  the  shaft  of  the  femur  was  present.  This  indi- 
cates the  character  of  the  disease  in  the  cases  operated  upon. 

In  99  of  the  119  cases  the  later  results  of  the  operation  were  ascer- 
tained. Of  these  52  were  dead  and  47  were  living.  Of  the  52  deaths 
9  were  due  directly  to  the  operation,  shock ;  28  were  caused  by  ex- 
haustion ;  9  by  tuberculous  meningitis  ;  7  by  other  causes.  Thirty- 
seven  deaths  occurred  within  six  months  and  10  others  within  one 
year  of  the  operation.  Of  the  47  patients  living  at  the  time  of  the  in- 
vestigation 26  were  cured.  Of  the  remaining  number  about  one  half 
were  in  poor  condition  so  that  recovery  could  not  be  expected.  It  is 
evident  that  in  a  large  proportion  of  the  cases  the  operation  was 
unsuccessful  as  a  life-saving  measure  since  suppuration  persisted. 

The  functional  results  in  these  cases  are  shown  in  the  table  on  the 
following  page. 

Lovett  ^  has  reported  the  results  of  50  excisions  in  a  similar  class  of 
cases  at  the  Boston  Children's  Hospital,  1877  to  1895.  The  number  of 
patients  actually  treated  in  the  wards  of  the  hospital  is  not  stated,  but 
1,100  cases  were  recorded  as  having  been  under  treatment  during  this 
time,  a  percentage  of  excisions  of  4.5  of  the  total  number.  In  eight  of 
the  cases  osteomyelitis  of  the  femur  was  present  and  in  1 5  the  acetabulum 
was  perforated.     The  ultimate  mortality  was  about  50  per  cent. 

Poor'^  has  reported  the  results  in  65  cases  operated  upon  at  St.  Mary's 
Hospital,  New  York,  with  a  final  mortality  of  about  43  per  cent.  In 
21  cases  osteomyelitis  of  the  shaft  of  the  femur  was  present.  In  11 
cases  there  was  perforation  of  the  acetabulum  and  in  9  of  these  the 
opening  communicated  with  an  intra-pelvic  abscess. 

These  statistics  are  quoted  to  illustrate  the  relative  efficiency  of  late 
excision.  The  extent  of  the  lesions  in  some  of  the  oases  shows  that 
recovery  would  have  been  impossible  without  operation,  and  its  failure 
to  relieve  the  symptoms  in  so  many  instances  is  sufficient  evidence  that 
it  was  postponed  too  long.     Under  proper  conditions  for  treatment  ex- 

1  Medical  News,  June  26,  1897.  2 Trans.  Am.  Ortho.  Ass'n,  Vol.  X. 

3K  Y.  Med.  Jour.,  April  23,  1892. 


292 


TUBERCULOUS  DISEASE  OF  THE  HIP  JOI^T 


cision  of  the  hip  is  almost  never  required,  but  in  hospital  practice  it 
"would  seem  that  it  should  be  performed  oftener  and  at  an  earlier  stage 
of  the  disease. 


Table   Showing  Shortening,  Motion,  Number  of  Sinuses   Present, 

AND  Angle  of  Greatest  Extension  in  47  Cases 

OF  Excision.     (Townsend.) 


No. 

Time  since  operation. 

General 
Condition. 

Sinuses 
present. 

Angle 
of  greatest 
extension. 

Motion  in 
degrees. 

Shortening 
in  inches. 

1 

6f  years. 

Good 

3 

150 

0 

2J 

2 

61:      " 

Fair 

1 

135 

0 

4 

3 

6       " 

Good 

0 

180 

100 

3 

4 

of     " 

" 

0 

180 

35 

3 

5 

5f     " 

Fair 

0 

145 

10 

4 

6 

5J     " 

Good 

1 

165 

0 

U 

7 

5       " 

(( 

0 

155 

5 

2i 

8 

4|     " 

it 

3 

160 

0 

2* 

9 

U     " 

u 

0 

160 

0 

2f 

10 

4   " 

il 

0 

165 

0 

H 

11 

4       " 

n 

0 

150 

0 

n 

12 

4       " 

Poor 

4 



0 

u 

13 

3*     " 

Good 

0 

'       155 

0 

u 

14 

3i     " 

a 

0 

160 

30 

1 

15 

3       " 

Poor 

1 

165 

0 

i 

16 

2       " 

Fair 

2 

145 

30 

i 

17 

2       " 

Good 

18 

2       " 

Fair 

1 

170 

0 

J 

19 

9         " 

Good 

0 

150 

0 

3 

20 

If  " 

li 

0 

175 

^ 

21 

If  " 

il 

0 

165 

"30 

* 

22 

1*   " 

If 

0 

150 

0 

1 

23 

1*    " 

li 

0 

150 

0 

u 

24 

li  " 

11 

1 

180 

0 

* 

25 

li  " 

Fair 

6 

175 

15 

1 

26 

1   " 

Poor 

2 

165 

0 

2^ 

27 

1   " 

Good 

0 

170 

0 

1* 

28 

1   " 

11 

0 

155 

0 

1 

29 

1   " 

11 

0 

175 

0 

1 

30 

1   " 

Poor 

0 

180 

10 

il 

31 

11  months. 

11 

3 

170 

0 

i- 

32 

10       " 

11 

0 

180 

40 

n 

33 

10       " 

Good 

3 

165 

0 

1 

^7 

34 

10       " 

11 

0 

160 

0 

I 

35 

10       " 

" 

1 

165 

0 

1 

36 

10       " 

Poor 

1 

160 

0 

I 

37 

10       " 

Good 

H 

155 

10 

li 

38 

9       " 

" 

1 

0 

* 

39 

9       " 

11 

0 

....„ 

h 

40 

9       " 

Pom- 

1 

170 

* 

41 

9       " 

Fair 

3 

1 

42 

8       " 

Good 

0 

180 

130 

i 

43 

8       " 

i( 

0 

180 

i 

44 

8       " 

Poor 

1 

165 

"10 

f 

45 

7       " 

(( 

46 

7       " 

Good 

0 

180 

10 

H 

47 

V 

u 

0 

160 

70 

i 

Amputation. — Amputation  at  the  hip  should  follow  excision  when, 
suppuration  persists  and  when  the  condition  of  the  patient  does  not 
improve,  provided  the  internal  organs  are  not  hopelessly  diseased^ 


REDUCTION  OF  FIXED  DEFORMITY. 


293 


Fig.  214. 


The  operation  of  amputation  after  complete  excision  is  a  simple  pro- 
cedure and  it  should  not  be  attended  with  great  danger. 

Reduction  of  Deformity  in  Resistant  Cases. — The  various  methods  of 
reducing  deformity  during  the  active  stages  of  the  disease  have  been 
described,  and  the  importance  of  preventing  deformity  throughout  the 
entire  course  of  treatment  has  been  insisted  on.  At  the  present  time, 
for  one  reason  or  another,  deformity  from  this  cause  is  very  common, 
either  because  its  importance  is  not  appreciated  or  because  it  is  con- 
sidered as  a  necessary  concomitant  of  the  disease,  treated  by  apparatus, 
as  it  is  in  the  natural  cure.  At  all 
events  in  many  instances  it  is 
allowed  to  persist  until  the  ac- 
commodative changes  about  the 
diseased  joint  have  so  fixed  the 
limb  in  the  deformed  position  that 
greater  correcting  force  is  re- 
quired than  can  be  applied  by  the 
weight  and  pulley  or  by  other 
method  of  traction. 

In  this  class  of  cases,  in  which 
the  muscles  are  structurally  short- 
ened and  in  part  transformed  to 
fibrous  tissue,  and  in  which  the 
anterior  wall  of  the  capsule  has 
become  retracted  and  it  may  be 
adherent  to  the  surrounding  parts, 
forcible  reduction  under  anaesthe- 
sia, or  osteotomy,  may  be  re- 
quired. If  the  disease  is  quies- 
cent, or  cured  ;  if  the  head  of  the 
femur  or  what  remains  of  it  is  in 
the  normal  position,  and  if  a  fair 
range  of  motion  remains,  grad- 
ual forcible  reduction  after  di- 
vision of  the  bands  of  fascia  or  the 
muscles  that  hold  the  limb  in  the 
deformed  position,  is  advisable. 
After  reduction  of  the  deformity 
in  one  or  more  sittings,  the  limb 
must  be  fixed  in  a  long  spica  bandage  and  held  in  this  position  by  this 
or  other  fixative  appliance,  until  the  tendency  to  deformity  has  been 
overcome. 

This  method  of  reducing  deformity  of  the  more  or  less  resistant 
type  has  been  performed  in  329  instances  at  the  Hospital  for  Ruptured 
and  Crippled  during  the  past  ten  years,  with  but  one  death  ;  from  fat 
embolism. 

The  Correction  of  Deformity  by  Femoral  Osteotomy. — If  the  deformity 
is  fixed  by  bony  anchylosis  or  by  firm  fibrous  adhesions  within  the 


Extreme  deformity  after  hip  disease.  (See  Figs. 
215,  216.)  Showing  the  attitude  in  standing  before 
operation. 


294 


TUBERCULOUS  DISEASE  OF  THE  HIP  JOINT. 


joint,  or  if  it  is  feared  that  violence  may  stimulate  dormant  disease ; 
or  if  there  is  such  a  degree  of  upward  displacement  of  the  femur  upon 
the  pelvis  that  the  deformity  is  Hkely  to  recur  after  replacement,  it  is 
better  to  correct  the  deformity  by  an  osteotomy  of  the  femur. 

The  patient  having  been  prepared  for  operation,  is  turned  upon  the 
side  and  a  sandbag  is  placed  between  the  thighs.  A  small  osteotome 
about  the  shape  of  a  lead  pencil,  of  which  one  extremity  is  flattened  to 
a  cutting  edge  (Vance's  instrument),  is  pushed  directly  through  the 
soft  parts  to  the  femur  at  a  point  about  two  inches  below  the  apex  of 
the  trochanter.  It  is  turned  until  its  cutting  edge  is  at  a  right  angle 
to  the  shaft  and  it  is  then  driven  through  the  cortical  substance  of  the 
bone.  When  it  has  penetrated  at  one  point  it  is  withdrawn,  and  ad- 
joining portions  are  cut  until  about  half  the  circumference  is  divided, 
when  with  slight  force  the  bone  may  be  fractured.  If  the  deformity 
is  of  long  standing,  division  of  the  contracted  tissues  in  the  adductor 
region  and  below  the  anterior  superior  spine,  may  be  required.     The 

Fig.  215. 


The  favorite  attitude  in  recumbency.    (See  Fig.  214. 


limb  is  then  drawn  down  to  complete  extension  and  moderate  abduc- 
tion and  the  body  and  limb  are  encased  in  a  plaster  of  Paris  spica 
bandage  which  should  remain  in  position  for  several  months,  although 
the  patient  may  be  allowed  to  bear  weight  on  the  limb  in  a  few  weeks 
after  the  operation. 

The  advantages  of  the  subcutaneous  method  are  simplicity  and  free- 
dom from  danger.  No  dressings  are  required,  except  a  pad  of  gauze 
over  the  minute  opening,  thus  the  limb  may  be  firmly  held  by  the 
plaster  bandage.  If  there  is  anchylosis  between  the  femur  and  the 
pelvis  no  support  will  be  required  after  the  bone  has  united,  but  if 
there  is  motion  in  the  joint,  some  fixative  appliance  should  be  em- 
ployed for  a  time,  to  prevent  recurrence  of  a  part  of  the  deformity. 

During  the  past  ten  years  this  operation  has  been  performed  147 
times  without  a  mishap,  at  the  Hospital  for  Ruptured  and  Crippled. 
It  is  especially  valuable  as  a  means  of  correction  of  extreme  and  dis- 
abling deformity. 

Prognosis.  Mortality. — The  direct  mortality  of  hip  disease 
is  due  almost  entirely  to  the  immediate  or  remote  effects  of  abscess. 


THE  MORTALITY  OF  HIP  DISEASE. 


295 


Fig.  216. 


This  is  illustrated  by  the  statistics  of  Bruns  in  which  the  mortality 
from  all  causes  of  the  non-suppurative  cases  was  23  per  cent,  as  com- 
pared with  52  per  cent,  in  those  in  which  suppuration  was  present. 

The  mortality  among  the  patients  treated  at 
many  of  the  German  clinics  is  much  higher  than 
in  the  corresponding  class  in  this  country. 

At  Tubingen,  according  to  Wagner/  it  was 
40  per  cent. 

At  Kiel,  according  to  Mummelthy,  it  was 
48.59  per  cent,  in  non-operative  cases  and 
53.96  per  cent,  in  operative  cases. 

At  Marburg,  according  to  Marsch,  it  was  35 
per  cent,  in  non-operative  cases  and  40.4  per 
cent,  in  operative  cases. 

At  Heidelberg,  according  to  Huismans,^  it 
was  46.6  per  cent,  in  non-operative  cases  and 
58  per  cent,  in  operative  cases. 

At  Zurich,  according  to  Pedolin,^  it  was  37.7 
per  cent,  in  non-operative  cases  and  54  per 
cent,  in  operative  cases. 

At  Vienna,  according  to  Prendlsburger,^  it 
was  17  per  cent,  in  all  classes. 

In  a  total  of  636  cases  treated  by  conser- 
vative methods  by  Kabl,  1859  to  1894,  defi- 
nite results  were  ascertained  in  519.^  335 
were  hospital  cases.  Of  these  216  were  cured, 
64.4  per  cent.  70  died,  20,8  per  cent.,  and 
49,  14.4  per  cent.,  were  still  under  treatment. 
184  were  treated  as  out-patients  ;  of  these  132 
were  cured,  71.5  per  cent.;  35  died,  19.2  per 
cent.,  and  17,  9.2  per  cent.,  remained  under 
treatment. 

In  288  cases  treated  at  the   Hospital  for 
Ruptured  and  Crippled,  New  York,  reported       After  correction  bv  osteotomy 
by  Gibney,*'  the  death  rate  was  12.5  per  cent,  suel'^'sif  Figl'^lit°2\r'tG'it 

In  private  practice  the  statistical  reports  of  ^^^^'^ 
final  results  show  the  death  rate  to  be  extremely  small.     C.  F.  Taylor,^ 
94  cases,  including  24  in  which  suppuration  was  presented,  3  deaths. 
L.  A.  Sayre,*  212  cases,  5  deaths.     Lorenz,^  60  cases  with  3  deaths. 

In  the  clinics  of  this  country  the  death  rate  has  been  estimated  to 

1  Beit.  z.  klin.  Chir.,  Bd.  13,  1895. 

2  Quoted  by  Binder,  Zeits.  f.  Orthop.  Chir.,  Bd.  7,  H.  2  and  3,  1889. 
^Centb.f.  Chir.,  No.  30,  July  25,  1896. 

*  Loc.  cit. 

5  Zur  Conserv.  Behand.  der  tuberculosen  Knochen  und  Gelenksleiden,  J.  Rabl,  Leip- 
zig und  Wein,  1895. 

^N.  Y.  Med.  Jour.,  July-August,  1877. 

^  Boston  Med.  and  Surg.  Jour.,  March  6,  1879. 

8N.  Y.  Jour.,  April  30,  1892. 

9  Wiener  Klinik,  10  and  11,  1892. 


296  TUBERCULOUS  DISEASE  OF  THE  HIP  JOINT. 

be  from  10  to  15  per  cent.,  a  rate  of  mortality  much  lower  than  that 
reported  from  those  abroad.  This  is  accounted  for,  in  part,  by  the 
fact  that  patients  are  of  a  better  class  and  in  part  because  they  receive 
earlier  and  more  efficient  mechanical  protection. 

The  causes  of  death,  according  to  Wagner's  statistics  of  124  cases, 
were  as  follows  : 

Hip  disease. 35 

General  tuberculosis 37 

Tuberculous  meningitis 13 

Tuberculosis  of  the  lungs 11 

Acute  miliary  tuberculosis 5 

Amyloid  degeneration 8 

Septic  infection 12 

Intercurrent  disease 3 

l24 

Thirty  per  cent,  of  the  deaths  occurred  in  the  first  year  of  the  dis- 
ease, 26  per  cent,  in  the  second  year  and  20.4  per  cent,  in  the  third  year. 

The  percentage  of  recovery  was  65  per  cent,  of  those  in  the  first  de- 
cade of  life,  56  per  cent,  of  those  in  the  second  and  but  28  per  cent, 
of  those  in  the  third  decade.  • 

The  causes  of  death  in  50  cases  among  778  patients  treated  at  the 
N.  Y.  Orthopgedic  Dispensary  and  Hospital  during  the  years  1877  to 
1882  were : ' 

Tuberculous  meningitis 20 

Amyloid  degeneration 5 

Exhaustion 3 

Tuberculosis  of  the  lungs 3 

Tuberculous  peritonitis 1 

Septicsemia 1 

Convulsions 1 

Unknown J^ 

50 

Of  96  deaths  recorded  at  the  Alexandra  Hospital,  London  (a  mor- 
tality of  about  26  per  cent,  of  the  cases  treated),  the  causes  were 

Tuberculous  meningitis 16.7  per  cent. 

Albuminuria  and  dropsy 20.8         " 

Tuberculosis  of  the  lungs 8.3         " 

Exhaustion 9.4 

Erysipelas  and  pysemia 3.1         " 

After  operation 9.4 

Intercurrent  diseases 7.3 

Unknown 25.0 

100.0  " 

The  direct  mortality  of  hip  disease  should  include  all  deaths  due  to 
operation,  those  caused  by  exhaustion  and  by  amyloid  degeneration, 
which  is  almost  always  the  result  of  profuse  suppuration  secondary  to 
pyogenic  infection.  While  tuberculous  meningitis  or  other  forms  of 
tuberculous  disease  may  have  been  due  to  new  infection  or  may  have 
been  caused  by  infection  from  the  primary  focus  which  preceded  the 
'Shaffer  and  Lovett,  N.  Y.  Med.  Jour.,  May  21,  1887. 


FUNCTIONAL  RESULTS.  297 

tuberculosis  of  the  hip,  although  exhausting  local  disease  by  lowering 
the  vital  resistance  would  still  be  an  indirect  cause  of  death. 

It  is  believed  that  operative  interference  is  sometimes  the  direct 
cause  of  tuberculous  meningitis,  and  it  is  of  interest  in  this  connection 
to  note  that  20  of  50  deaths,  or  rather  of  34,  in  which  the  cause  of 
death  was  known,  58  per  cent,  "were  due  to  this  complication  among 
the  cases  treated  at  the  New  York  Orthopaedic  Dispensary  and  Hos- 
pital where  no  operations  were  performed.^  AVhile  of  52  deaths  in  a 
total  of  99  cases  treated  at  the  Hospital  for  Ruptured  and  Crippled,  in 
which  excision  was  performed,  but  9  were  caused  by  tuberculous  men- 
ingitis.^ 

The  normal  death  rate  among  cases  under  fair  hygienic  conditions 
is  illustrated  by  statistics  from  the  Hospital  for  Ruptured  and  Crip- 
pled, at  a  time  when  no  operative  or  mechanical  treatment  was  em- 
ployed.^ This  was  12.5  per  cent.  :  4.5  per  cent,  from  exhaustion, 
4.5  per  cent,  from  amyloid  degeneration,  1.75  per  cent,  from  tubercu- 
lous meningitis,  1.75  per  cent,  from  intercurrent  diseases. 

Thus  nearly  75  per  cent,  of  the  deaths  were  due  more  or  less  di- 
rectly to  suppuration. 

Functional  Results. — In  a  certain  proportion  of  cases  perfect 
function  may  be  retained,  the  proportion  depending  upon  the  extent  of 
the  disease,  and  upon  the  timeliness  and  efficiency  of  the  treatment. 

In  a  total  of  two  hundred  and  eighty  cases  from  the  private  practice  of 
Dr.  L.  A.  Sayre,*  in  which  the  final  results  were  known,  seventy-three  or 
26  per  cent,  recovered  with  perfect  motion,  and  one  hundred  and  twenty 
or  42  per  cent,  retained  good  motion.  These  results  are  extraordinarily 
good,  very  much  better  than  any  others  that  have  been  reported,  and  of 
course  far  better  than  may  be  expected  in  the  ordinary  class  of  cases. 

The  effect  of  mechanical  treatment  and  of  the  various  measures  em- 
ployed for  the  correction  of  deformity  is  well  illustrated  in  two  series 
of  ultimate  results  in  cases  treated  at  the  Hospital  for  Ruptured  and 
Crippled,  reported  by  Gibney.^  In  the  first  series  of  80  cases  no  me- 
chanical or  operative  measures  were  employed,  the  treatment  being 
simply  hygienic  and  symptomatic ;  the  results  therefore  represent  nat- 
ural cure  under  proper  supervision.  The  duration  of  the  disease  was 
3  years  in  twenty-three,  3  to  6  years  in  twenty-eight,  6  to  10  years  in 
sixteen  and  15  years  in  one  case. 

In  thirty-five  cases  the  shortening  was  two  inches  or  more,  and  in 
nearly  every  case  there  was  more  or  less  deformity,  viz. : 

In    2  there  was  flexion  to    90  degrees. 

In    3  "  " 

In    3  "  " 

•  In  19  "  " 

In  19  "  " 

In  18  "  " 

In  11  "  " 

'Shaffer  and  Lovett,  N.  Y.  Med.  Jour.,  May  21,  1887 

2Townsend,  Med.  News,  June  26,  1896. 

3Gibney,  N.  Y.  Med.  Record,  March  2,  1878.      ^luoc.  cit 


110 

120 

135 

145 

150 

160-170 

21,  1887. 

« N.  Y. 

Med.  Jour., 

,  April  30,  1892. 

298  TUBERCULOUS  DISEASE  OF  THE  HIP  JOINT. 

In  4  no  estimate  was  made.  Distortions  other  than  flexion  are  not 
specified. 

In  12  instances  motion  was  retained  of  from  15  to  90  degrees. 

In  the  second  series  ^  of  one  hundred  and  seven  cured  cases,  mechanical 
and  operative  treatment  was  employed  although  the  protection  assured 
was  in  many  instances  far  from  efficient.  In  many  of  these  cases  the 
disease  was  in  an  advanced  stage,  and  deformity  was  present  in  more 
than  half  of  the  number  when  treatment  was  begun,  and  yet  all  of 
them  recovered  without  marked  flexion  and  presumably  without  ad- 
duction, as  this  deformity  is  not  mentioned. 

47  had  no  flexion. 

30     "■    flexion  to  170  to  180  degrees. 
20     "  "  160  "  170         " 

10     "  "  150  "  160        " 

Perfect  motion  was  retained  in  13. 
Good  motion  was  retained  in  22 
Limited  motion  was  retained  in  41. 
In  31  there  was  anchylosis. 

In  69  cases  the  shortening  was  one  inch  or  less,  35  having  no 
shortening.     In  38  it  was  more  than  one  inch. 

As  has  been  stated,  the  mechanical  treatment  was  not  sufficiently 
effisctive  to  prevent  deformity  and  to  attain  these  results  osteotomy 
with  or  without  division  of  contracted  tissues  was  performed  in  19 
cases ;  forcible  correction  with  or  without  tenotomy  in  30  cases  and  in 
4  cases  the  joint  was  excised. 

If  the  joint  has  been  actually  invaded  by  disease  so  that  a  part  of  its 
articulating  surface  has  been  destroyed,  motion  must  be  impeded  both 
in  area  and  quality.  In  such  cases  the  joint  is  usually  somewhat 
weakened  although  not  to  the  extent  of  interfering  seriously  with  the 
ability  of  the  patient.  In  many  instances,  discomfort  in  damp  weather 
or  pain  on  over-exertion,  is  experienced,  symptoms  similar  to  those 
complained  of  by  rheumatic  subjects. 

Simple  shortening,  due  to  retardation  of  growth,  unaccompanied  by 
deformity,  is  of  comparatively  little  importance.  Anchylosis  in  a  sym- 
metrical position  insures  a  strong  and  useful  limb,  the  flexibility  of  the 
lumbar  region  compensating  for  the  loss  of  motion  at  the  joint.  In 
such  cases  the  disability  may  be  very  slight,  and  the  effect  of  the  loss 
of  motion  may  be  more  apparent  in  the  sitting  than  in  the  erect  pos- 
ture, for  the  patient  must,  as  it  were,  sit  upon  his  back,  an  attitude 
which  perceptibly  reduces  the  sitting  height. 

Flexion,  if  it  be  slight  does  not  cause  disability,  but  flexion  of  more 
than  30  degrees  increases  the  lumbar  lordosis  and  makes  the  buttock 
prominent,  the  deformity  so  characteristic  of  the  natural  cure.  (Fig. 
166.)  Great  flexion,  for  example  of  60  or  90  degrees,  causes  an  ex- 
aggerated lordosis  which  is  almost  always  a  source  of  pain  or  discom- 
fort to  a  patient  who  is  obliged  to  stand  much  of  the  time. 

Abduction  is  of  no  importance  unless  it  be  considerable.  It  serves 
in  most  instances  as  a  compensation  for  actual  shortening  of  the  limb. 
1  Gibney,  "Waterman  and  Reynolds,  Trans.  Am.  Ortli.  Ass'n,  Vol.  XI.,  1898. 


DEFORMITIES  OF  OTHER  PARTS,  CAUSED  BY  HIP  DISEASE.    299 

Adduction,  on  the  other  hand,  which  necessitates  an  upward  tilting 
of  the  pelvis  in  order  to  restore  the  parallelism  of  the  limbs,  is  the 
most  disastrous  of  all  the  distortions  since  it  causes  a  practical  shorten- 
ing often  greater  than  that  due  to  the  destructive  effects  of  the  disease. 

Deformities  of  Other  Parts,  caused  by  Hip  Disease. — De- 
formities of  other  parts  are  sometimes  observed  as  secondary  results 
of  hip  disease,  most  often  in  cases  that  have  not  received  proper  treat- 
ment. In  the  spine  an  exaggerated  lordosis  as  a  compensation  for 
flexion  is  not  uncommon,  and  lateral  curvature  may  follow  dis- 
tortion of  the  pelvis  caused  by  adduction.  In  the  limb,  knock  knee 
may  follow  persistent  adduction  of  the  thigh  or  it  may  be  an  effect 
of  laxity  of  the  ligaments,  without  such  distortion.  Another  defor- 
mity is  genu  recurvatum.  This  is  apparently  caused  by  long-con- 
tinued disuse  of  the  limb  and  by  the  use  of  apparatus  in  which  the 
knee  has  not  been  properly  supported.  It  is  supposed  to  be  one  of  the 
effects  of  traction,  but  it  is  also  observed  in  cases  in  which  traction 
has  never  been  employed.  In  cases  in  which  the  muscular  atrophy 
that  follows  limited  motion  and  long-continued  disuse,  is  great,  laxity 
OF  THE  LIGAMENTS  of  the  kuec  joint  is  common.  A  slight  degree  of 
EQUINUS  with  accompanying  exaggeration  of  the  arch,  is  not  uncom- 
mon among  patients  who  have  been  treated  by  the  traction  apparatus, 
in  which  the  foot  is  pendant  and  in  which  the  toes  are  often  inclined 
downward  to  guide  the  brace  in  walking.  Practically  speaking,  all 
these  secondary  deformities  may  be  avoided  by  proper  supervision  of 
the  patient  during  the  period  of  treatment. 

As  a  rule,  patients  who  have  recovered  from  hip  disease  finally  dis- 
card all  apparatus,  or  at  most  use  only  a  cane  as  a  support,  and  many 
prefer  to  walk  habitually  on  the  toe  rather  than  to  equalize  the  length 
of  the  limbs  by  a  high  shoe. 

In  conclusion  it  may  be  stated  that  by  far  the  larger  number  of 
this  class,  having  accommodated  themselves  to  whatever  weakness  and 
distortion  may  be  present  are  able  to  undertake  the  ordinary  occupa- 
tions of  life.  Of  the  patients  cured  at  the  New  York  Orthopaedic  Dis- 
pensary and  Hospital  in  the  report  already  referred  to,  in  whom  the 
final  results  as  regards  motion  and  symmetry  were  certainly  not  above 
the  average,  it  is  stated  that  there  was  not  a  single  individual  who  was 
incapacitated  from  doing  a  full  day's  work  at  his  or  her  trade  or  occupa- 
tion.    None  used  crutches  and  but  one  used  a  cane. 


CHAPTER    VIII. 
NON-TUBERCULOUS  AFFECTIONS  OF  THE  HIP  JOINT. 

Traumatisms  at  the  Hip. 

It  is  probable  that  injury  at  the  hip  joint,  caused  by  falls  or  strains, 
may  induce  congestion  about  the  epiphyseal  cartilage  of  the  head  of  the 
femur  and  consequent  discomfort,  a  variety  of  the  so-called  growing 
pain.  In  this  class  of  cases  there  may  be  a  limp  and  restriction  of  mo- 
tion that  may  disappear  in  a  few  days  or  that  may  recur  from  time  to 
time.  If  the  injury  is  more  severe  there  may  be  local  sensitiveness  and 
even  swelling — synovitis.  This  congestion  may  be  a  predisposing  cause 
of  tuberculous  disease  and  it  is  probable  that  cases  of  this  type  are  some- 
times mistaken  for  hip  disease  and  go  to  swell  the  number  of  perfect 
functional  results  that  are  attained  by  one  or  another  system  of  treatment. 

Treatment. — All  cases  of  this  class  require  careful  treatment  and 
supervision.  Strains  or  other  injuries,  in  young  children,  are  best 
treated  by  a  supporting  bandage  and  by  rest  in  bed  until  the  symp- 
toms disappear.  If  the  sensitive  condition  persists,  protective  treat- 
ment by  a  brace,  preferably  the  ordinary  traction  hip  splint,  should  be 
employed,  the  diagnosis  being  reserved  until  it  is  made  clear  by  the 
progress  of  the  case.  Chronic  synovitis  of  the  hip  joint,  especially  in 
the  adolescent  or  adult,  unless  it  be  a  result  of  severe  injury,  is  usually 
tuberculous  in  character. 

Fracture  of  the  neck  of  the  femur  in  childhood  will  be  considered  in 
connection  with  coxa  vara. 

Acute  Infectious  Arthritis ;  Acute  Epiphysitis  at  the  Hip. 

Acute  epiphysitis,  caused  by  infection  with  pyogenic  germs,  is  not 
uncommon  in  infancy  and  early  childhood  and  it  often  passes  as  a  form 
of  acute  tuberculous  disease.  In  fifty-two  cases  in  which  but  a  single 
joint  was  involved  the  hip  was  affected  in  twenty-six.^  In  some  in- 
stances it  is  caused  apparently  by  injury,  in  others  it  is  secondary  to 
an  infected  wound  and  not  uncommonly  it  follows  pneumonia  or  one 
of  the  exanthemata.     (See  page  211.) 

Symptoms. — The  symptoms  are  of  sudden  onset,  accompanied  usu- 
ally by  high  fever  and  prostration.  The  hip  becomes  swollen,  hot, 
and  sensitive  both  to  motion  and  pressure. 

Treatment. — The  treatment  is  early  and  free  incision  and  efficient 

drainage,  the  limb  being  afterwards  supported  by  some  form  of  splint. 

The  suppuration  ordinarily  persists  for  several  months  ;  the  epiphysis 

is  usually  destroyed  and  in  consequence  the  joint  becomes  somewhat 

'  Townsend,  Am.  Jour.  Med.  iSci.,  Jan.,  1890. 


EXTRA- ARTICULAR  DISEASE. 


301 


Fig.  217. 


loose  and  flail-like.  (Fig.  217.)  Many  of  these  cases  seen  in  later 
years;  but  for  the  history  and  the  scars  about  the  joint,  might  be  mis- 
taken for  congenital  dislocation.  In  certain  instances  the  symptoms 
are  less  acute  and  the  diagnosis  from  tuberculous  disease  can  be  made 
positively  only  after  a  bacteriological  examination  of  the  fluid  that  may 
be  removed  from  the  joint  by  aspiration. 

In  the  class  of  cases  in  which  the  disease  is 
confined  to  one  joint  and  in  which  the  shaft  of 
the  bone  is  not  involved,  the  prognosis  is  good 
if  the  pus  is  thoroughly  evacuated.  In  twelve 
cases  treated  at  the  Hospital  for  Ruptured  and 
Crippled  there  were  three  deaths.^  The  prog- 
nosis as  to  function  under  these  conditions  is 
much  better  than  in  tuberculous  disease. 

After  recovery,  the  joint  should  be  support- 
ed for  a  time,  to  prevent  upward  displacement. 

In  the  forms  of  arthritis  that  may  compli- 
cate infectious  diseases  several  joints  are 
usually  involved  and  the  aifection  is  often 
subacute  in  character. 

Spontaneous  Dislocation  of  the  Hip. 
— If  the  hip  joint  becomes  distended  with 
fluid  the  capsule  may  be  ruptured  and  sudden 
displacement  may  occur. 

Degez,^  has  collected  from  literature  79 
cases  of  this  character.  The  displacement  oc- 
curred in  the  course  of  the  following  diseases  : 

Typhoid  fever 32 

Rheumatism 24 

Scarlatina  13 

Variola 3 

Gonorrhoeal  arthritis 3 

Grippe 2 

Erysipelas 1 

Eruptive  fever  1 


The  effect  of  acute  epiphysitis 
of  the  right  liip  at  three  months  of 
age.    The  scar  is,  shown. 


Such  accidents  may  be  guarded  against  by 
preventing  flexion  and  adduction  of  the  limb 
and  by  an  evacuation  of  the  fluid  that  distends 
the  joint.     The  femur  may  be  replaced  if  an 

opportunity  is  oiFered,  before  it  has  become  fixed  by  adhesions  and  con- 
tractions. Once  replaced  it  must  be  held  in  proper  position  for  a  time, 
by  apparatus. 

Extra- Articular  Disease. 

Occasionally  tuberculous  disease,  or  other  form  of  destructive  osti- 
tis, may  begin  in  the  neighborhood  of  the  trochanter  major.  The 
symptoms  are  local  pain,  sensitiveness  and  swelling  of  the  soft  parts, 
and  thickening  and  irregularity  of  the  underlying  bone. 

'Townsend,  loc.  cit.  ^jjgy^g  d' Ortliopedie,  January  1,  1899. 


302      NON-TUBERCULOUS  AFFECTIONS  OF  THE  HIP  JOINT. 

Tlie  treatment  is  prompt  removal  of  the  focus  of  disease,  before  the 
joint  or  the  shaft  of  the  femur  has  become  involved. 

Malignant  Disease  of  the  Hip  Joint. 

Carcinoma  of  the  upper  extremity  of  the  femur  is  almost  always 
secondary  to  a  primary  tumor  of  another  part  of  the  body.  Sarcoma 
is  far  less  frequent  in  this  situation  than  at  the  knee.  The  character 
of  the  disease  soon  becomes  evident  in  the  general  enlargement  of  the 
upper  extremity  of  the  thigh,  but  in  the  early  stage  diagnosis  can  be 
made  only  by  means  of  the  X-ray  or  by  exploratory  incision. 

Cysts  of  the  Femur. 

In  extremely  rare  instances  cysts,  caused  apparently  by  inclusion  of 
a  displaced  portion  of  epiphyseal  cartilage,  may  cause  enlargement, 
weakening  and  deformity  of  the  upper  extremity  of  the  femur.  In 
one  case,  treated  at  the  Hospital  for  Kuptured  and  Crippled,  discom- 
fort, limp  and  outward  bowing  of  the  femur  in  a  boy  thirteen  years 
of  age,  was  found  on  examination  to  be  caused  by  a  cyst  of  this  char- 
acter.    Relief  followed  its  removal. 

Gluteal  Bursitis. — An  enlargement  of  one  of  the  bursse  lying 
beneath  the  gluteal  muscles,  may  cause  a  rounded,  fluctuating  swelling 
in  the  buttock.  It  may  be  painful  to  pressure  and  it  usually  causes  a 
limp,  and  some  discomfort  on  motion,  dependent  upon  the  degree  of 
inflammation  that  may  be  present.  Occasionally  the  bursitis  may  be 
caused  by  injury,  but  in  most  instances  it  is  the  result  of  tuberculous 
infection.  The  bursa  may  communicate  with  a  diseased  hip  joint,  but 
usually  it  is  a  distinct  and  primary  inflammation. 

Ilio-Psoas  Bursitis. — This  causes  a  distinct  swelling  on  the  upper 
and  inner  aspect  of  the  thigh.  It  is  usually  accompanied  by  slight 
flexion,  abduction  and  outward  rotation  of  the  limb,  an  attitude  that 
relieves  the  tension  on  the  sensitive  part.  Zuelzer  has  collected  from 
literature  45  cases  of  gluteal  and  15  of  ilio-psoas  bursitis.  This  illus- 
trates the  relative  frequency  of  the  two  afi'ections.^ 

Simple  bursitis  may  be  distinguished  from  disease  of  the  joint  by  the 
absence  of  characteristic  muscular  spasm  and  general  limitation  of 
motion. 

Treatment. — Chronic  disease  of  bursse  is  usually  tuberculous  in 
character,  thus  radical  removal  of  the  sac  is  advisable.  Aspiration  and 
injection  of  carbolic  acid  or  iodoform  emulsion  may  be  employed  as 
primary  measures. 

ARTHRITIS    DEFORMANS. 
Osteo- arthritis  of  the  Hip  Joint. 

Osteo-arthritis,  in  certain  instances,  may  be  confined  to  the  hip  joint. 
In  this  form  it  is  an  affection  of  adult  life  or  old  age.     It  is  character- 

'Deutsch  Zeits.  f.  Chir.,  Bd.  50,  H.  1  and  2. 


ARTHRITIS  DEFORMANS.  303 

ized  by  disappearance  of  the  cartilage  covering  the  head  of  the  femur 
and  by  an  eburnation  and  progressive  destruction,  or  wearing  away,  of 
the  underlying  bone.  At  the  same  time  there  is  formation  of  ecchon- 
droses,  about  the  margin  of  the  femur  and  the  acetabulum,  which  be- 
come ossified  into  irregular  masses  of  bone.  In  the  early  stage  of  the 
aifection  the  fluid  within  the  joint  may  be  increased  in  amount,  but 
later  it  is  diminished  in  quantity  and  changed  in  quality  as  the  synovial 
membrane  becomes  transformed  in  part  to  fibrous  tissue.      (See  p.  212.) 

Symptoms. — The  early  symptoms  are  neuralgic  pain  in  the  limb, 
^'  sciatic  rheumatism "  and  sensitiveness  about  the  joint  so  that  the 
patient  lies  habitually  on  the  other  side.  The  movements  of  the  joint 
become  somewhat  restricted  and,  in  certain  instances,  creaking  sounds 
are  apparent  to  the  patient.  In  the  advanced  stages  of  the  disease, 
there  is  marked  thickening  about  the  trochanter  which  is  usually  dis- 
placed upward,  owing  to  the  progressive  changes  in  the  head  and  neck 
of  the  femur ;  and  the  limb  is  distorted  in  flexion  and  adduction, 
symptoms  that,  but  for  the  history,  might  be  mistaken  for  the  results 
of  fracture  of  the  neck  of  the  femur.  While  in  the  earlier  period  of 
the  disease  the  limp,  the  pain  and  restriction  of  motion  with  the  attend- 
ant atrophy  may  simulate  very  closely  tuberculous  disease  of  a  sub- 
acute type. 

Treatment. — In  the  class  of  cases  in  which  the  disease  is  confined 
to  a  single  joint  and  in  which  the  symptoms  are  dependent  upon  the 
destruction  of  the  joint,  protective  treatment  is  indicated. 

If  deformity  be  present  it  should  be  reduced  by  traction  and  rest  in 
bed.  Afterwards  the  symptoms  may  be  relieved  by  the  use  of  a  hip 
splint  (Fig.  205)  that  will  remove  the  weight,  and  limit  the  range  of  mo- 
tion somewhat.  In  most  instances  such  treatment  is  not  feasible,  but 
the  use  of  a  firm  flannel  spica  bandage,  combined  with  the  application 
of  cautery,  from  time  to  time,  adds  to  the  comfort  of  the  patient. 


CHAPTER    IX 


TUBERCULOUS   DISEASE   OF   THE   KNEE   JOINT. 


Fig.  218. 


Synonyms. — White  Swelling,  Tumor  Albus. 

Tuberculous  disease  of  the  knee  joint  is  next  in  frequency  and  impor- 
tance to  that  of  the  hip.  It  is  however  far  less  dangerous  to  life,  and  the 
prognosis,  as  regards  function,  is  much  better  than  in  the  former  affec- 
tion. This  is  explained  by  the  simplicity  of  the  joint  and  by  its  situ- 
ation at  a  distance  from  the  trunk,  at  the  junction  of  two  levers  of 
nearly  equal  length  and  size.     Thus  the  problem  of  treatment,  and 

more  especially  of  protection  by  mechanical 
means,  is  comparatively  simple;  consequently 
it  is  more  often  applied,  and  in  proportion  to 
its  efficiency  the  injury  of  functional  use  is  les- 
sened and  the  tendency  to  deformity  is  checked. 
Pathology. — The  disease  may  begin  in  the 
epiphysis  of  the  femur  or  in  that  of  the  tibia, 
occasionally  in  the  patella  or  in  the  head  of  the 
fibula,  or  primarily  in  the  synovial  membrane. 
In  547  cases,'  about  two-thirds  of  which 
were  in  adults,  treated  at  Koenig's  clinic  in 
Gottingen  by  operative  procedures  which  per- 
mitted inspection  of  the  joint,  281  (51.4  per 
cent.)  were  apparently  examples  of  primary 
osteal  disease ;  266  (48.6  per  cent.)  were  pri- 
marily synovial.  The  focus  was  in  the  femur 
in  93  instances  (33.1  per  cent.),  in  the  tibia 
in  107  (38.1  per  cent.),  in  the  patella  in  33 
(11.7  per  cent.),  and  in  more  than  one  bone  in 
48  (17.1  per  cent.). 

The  examination  of  a  joint  permitted  by 
arthrectomy  or  excision,  can  not  be  sufficiently  thorough  to  exclude 
disease  of  the  bone  and  to  establish  the  diagnosis  of  primary  disease 
of  the  synovial  membrane,  but  in  92  instances  the  opportunity  was 
offered  by  amputation  at  the  thigh,  eighty  of  the  patients  being  adults. 
This  examination,  presumably  thorough,  showed  the  primary  disease 
to  be  of  the  bone  in  50  cases,  while  in  35  the  synovial  membrane  was 
apparently  the  seat  of  the  primary  affection. 

In  17  of  the  50  cases  in  which  the  disease  was  osteal,  the  focus  was 
in  the  femur ;  in  7  it  was  in  the  internal  condyle,  in  6  in  the  external 

'Die  Specielle  Tubcrculose  der  Knocken  mu\  Gelcke,  Berlin,  1896. 


Section  of  the  knee  joint  at 
the  age  of  seven  years,  showing 
the  epiphyses  of  the  femur  and 
tibia  and  their  relation  to  the 
capsule.     (Krause.) 


STATISTICS.  305 

condyle  and  it  was  in  other  situations  in  4  cases.  In  17  the  primary- 
disease  nvas  of  the  tibia  ;  in  5  of  the  internal  tuberosity,  in  5  of  the  ex- 
ternal tuberosity,  in  other  situations  7.  In  5  instances  the  primary 
disease  was  of  the  patella,  and  more  than  one  bone  was  involved  in 
1 1  cases.  Nichols  '  states  that  he  has  examined  120  tuberculous  joints 
of  adults  and  children,  after  excision,  amputation  and  at  autopsy,  and 
in  every  instance  primary  foci  in  the  bone  Avere  discovered.  He  be- 
lieves primary  disease  of  the  synovial  membrane  to  be  very  uncommon 
and  asserts  that  examinations  are  of  no  particular  value  as  establishing 
the  absence  of  primary  osteal  disease  unless  the  bones  are  sawed  into 
thin  sections.  This  is  the  view  generally  held  in  this  country,  that  in 
the  great  majority  of  cases  the  disease  of  the  bone  precedes  the  disease 
in  the  interior  of  the  joint.  From  the  clinical  standpoint,  however, 
one  recognizes  two  distinct  types  of  tuberculous  disease  :  one,  beginning 
as  a  chronic  synovitis  in  which  the  early  symptoms  are  subacute,  a  type 
more  often  seen  in  adults  (Fig.  220) ;  and  the  more  common  class,  in 
which  the  symptoms  of  pain,  muscular  spasm  and  deformity,  seem  to 
indicate  clearly  a  primary  disease  of  the  bone. 

The  proximity  of  the  active  disease  in  the  neighborhood  of  the  joint 
sets  up  a  sympathetic  hypersemia  within  it,  and  an  accompanying 
synovitis.  If  the  disease  is  progressive  the  synovial  membrane  be- 
comes thickened  and  adhesions  form  between  its  folds  that  gradually 
lessen  the  capacity  of  the  joint  and  diminish  its  mobility.  When  per- 
foration takes  places  the  granulation  tissue  spreads  over  the  surface  of 
the  cartilages  destroying  them  in  its  progress  and  eroding  the  under- 
lying bone;  or  if  the  joint  is  filled  with  tuberculous  pus  they  may  be 
macerated  and  separated  in  necrotic  shreds.  The  direct  destructive 
effects  of  the  disease  are  increased  by  pressure  and  friction  when 
the  part  is  not  protected  by  mechanical  means.  The  hypertrophied 
synovial  membrane  and  the  thickened  and  diseased  capsule  cause  the 
peculiar  elastic  resistance  on  palpation,  called  pseudo-fluctuation. 
In  more  advanced  cases  there  is  also  a  reactive  inflammation  in  the 
over-lying  tissues,  accompanied  by  a  formation  of  fibrous  tissue  that 
involves  the  tendons  and  muscles.  These  changes  within  and  with- 
out the  joint  cause  the  firm  resistant  tumor  characteristic  of  "  white 
swelling." 

Etiology. — The  etiology  of  tuberculous  disease  has  been  discussed  in 
Chapters  V.  and  YII. 

Statistics. — Tuberculosis  of  the  knee-joint  is  essentially  a  disease  of 
early  life  although  it  is  less  strictly  confined  to  childhood  than  is  dis- 
ease of  the  spine  or  hip.  Sex  exercises  but  little  influence  and  the  two 
sides  are  affected  in  nearly  equal  numbers.  These  points  are  illustrated 
by  the  following  table  of  1,000  consecutive  cases  treated  at  the  Hos- 
pital for  Ruptured  and  Crippled.^ 

"Trans.  Am.  Orth.  Ass'n,  Vol.  XI. 

2  These  statistics,  together  with  those  of  tuberculous  disease  of  the  joiuts,  other  than 
of  the  hip,  were  collected  for  me  by  Drs.  F.  C.  Bradner,  S.  E.  S])rague,  E.  L.  Barnett, 
find  S.  W.  Stone,  House  officers  at  the  Hospital,  1900-1901. 

20 


306  TUBERCULOVS  DISEASE  OF  THE  KNEE  JOINT. 

Age  at  Incipiency  of  Knee  Joint  Disease. 

1  year  or  less 25     22  years  old 13 

2  years  old 45     23       "       "  12 

3  "  "  91  24  "       "  8 

4  "  "  164  25  "       "  3 

5  "  "  84  26  "       "  2 

6  "  "  75  27  "       "  4 

7  "  "  66  28  "       "  5 

8  "  "  74  29  "       "  7 

9  "  "  65  30  "       "  1 

10  "  "  60  31  "  "  1 

11  "  "  46  32  "  "  2 

12  "  "  20  33  "  "  1 

13  "  "  19  34  "  ''  1 

14  "  "  17  35  "  "  4 

15  "  "  12  36  "  "  0 

16  "  •'  10  37  ''  "  2 

17  "  "  20  38  "  "  1 

18  "  "  8  39  "  "  1 

19  "  "  8  40  "  "  1 

20  "  "  8  41  "  "  1 

21  "  "  12  50  "  "■  1 

Total     1,000 
Males  512— Females  488.     Right  485— Left  515. 

Symptoms. — The  general  characteristics  of  tuberculosis  have  been 
described  in  the  chapters  on  Pott's  disease  and  hip  disease.  In  the 
description  of  these  aflFections,  however,  but  little  stress  was  laid  on 
local  sensitiveness  and  local  swelling  because  in  these  situations  the  dis- 
eased parts  lie  at  a  distance  from  the  surface  and  are  concealed  by  the 
muscles  and  other  tissues.  At  the  knee,  on  the  other  hand,  the  joint 
is  superficial,  and  even  slight  effusion  into  the  capsule  changes,  to  a 
perceptible  degree,  its  contour,  while  sensitiveness  to  pressure,  eleva- 
tion of  the  local  temperature  and  thickening  of  the  tissues  are  usually- 
present. 

Even  when  the  patients  are  seen  at  a  comparatively  early  stage  of 
the  disease,  as  regards  the  physical  condition  of  the  joint,  the  history 
of  the  affection  will  almost  always  show  that  it  is  chronic  and  progres- 
sive in  character.  The  importance  of  establishing  this  fact  has  been 
mentioned  in  the  consideration  of  hip  disease,  and  it  may  be  stated 
again  that  a  chronic  painful  disease  of  a  joint,  accompanied  by  a  ten- 
dency to  deformity,  is,  in  childhood,  almost  always  tuberculous  in 
character. 

The  symptoms  of  tuberculous  disease  may  be  classified  as  limp,  pain, 
local  heat,  sensitiveness  and  swelling,  muscular  spasm  and  limitation  of 
motion,  distortion  and  atrophy. 

On  physical  examination  one  will  note  the  character  of  the  limp,  and 
the  slight  fliexion  of  the  limb  which  usually  accompanies  it.  The  joint 
is,  as  a  rule,  somewhat  enlarged,  and  the  normal  depressions  about  the 
patella  and  the  projection  of  the  component  bones,  are  less  accentuated 
than  on  the  opposite  side.     There  is  usually  slight  local  elevation  of 


SYMPTOMS. 


307 


temperature  and  sensitiveness  to  pressure,  varying  in  degree  with  the 
character  of  the  disease.  In  certain  cases  a  degree  of  effusion  is  present, 
sufficient  to  cause  the  symptoms  of  synovitis,  but  in  most  instances  the 
swelling  is  due,  in  great  part,  to  the  hypersemia  and  thickening  of  the 
synovial  membrane  and  the  capsule,  which  gives  the  sensation  of  elastic 
resistance  rather  than  actual  fluctuation. 

The  most  important  sign  is  limitation  of  the  range  of  motion  caused 
by  muscular  spasm.  The  normal  range  is  from  complete  extension,  180 
degrees,  to  a  degree  of  flexion, 

limited  only  by  the  apposition  Fig.  219. 

of  the  calf  and  the  posterior 
surface  of  the  thigh.  Even  in 
the  early  stage  of  disease,  a 
slight  limitation  of  complete 
extension  is  present,  due  to  re- 
flex muscular  spasm,  and  usu- 
ally a  corresponding  limitation 
of  the  complete  flexion ;  on 
sudden  movements,  the  char- 
acteristic reflex  contraction  of 
the  muscles  is  apparent.  In 
most  cases  this  limitation  of 
motion  and  consequent  flexion 
deformity,  is  well  marked  on 
the  first  examination.  Atrophy 
of  the  muscles  of  the  thigh  and 
calf,  dependent  upon  the  dura- 
tion of  the  disease  and  upon 
the  interference  with  function, 
is  present,  and  this  atrophy  is 
more  noticeable  because  of  the 
enlargement  of  the  knee. 

In  certain  cases,  more  often 
seen  in  infancy  and  early 
childhood,  the  symptoms  are 
more  acute  and  the  progress 
of  the  disease  is  more  rapid,  so 
that  it  may  simulate  an  infec- 
tious epiphysitis.    (Fig.  219.) 

In  another  type,  which  is  more  common  in  adults,  the  early  symp- 
toms are  very  similar  to  those  of  simple  chronic  synovitis.  The  joint 
is  swollen  by  a  distension  of  the  capsule,  pain  is  not  marked  and  mus- 
cular spasm  and  limitation  of  motion  are  evident  only  after  a  careful 
examination.  In  this  class  months  or  years  may  pass  before  the 
symptoms  become  as  disabling  as  when  they  are  characteristic  of  the 
osteal  type  of  the  disease. 

Primary  and  Secondary  Distortions  of  Knee  Joint  Disease. 
— At  the  hip  joint,  in  which  the  range  of  motion  is  extensive,  the  de- 


Acute  tuberculous  arthritis  of  the  knee. 


508 


TUBERCULOUS  DISEASE   OF  THE  KNEE  JOINT. 


Fig.  220. 


formities  resulting  from  disease  are  somewhat  complex,  causing,  for 
example,  apparent  shortening  or  lengthening,  according  as  the  limb  is 
adducted  or  abducted.  But  the  movements  that  the  knee  joint  permits 
are  much  simpler,  and  the  primary  distortion  is  simply  flexion.  Com- 
plete extension  of  the  limb,  the  limit  of  normal  motion  in  that  direction, 
brings  the  joint  surfaces  into  close  apposition  ;  the  ligaments  are  then 
tense  and  no  lateral  motion  is  permitted.  This  is  the  attitude  in  which 
the  greatest  efficiency  of  the  limb  for  weight-bearing,  is  assured.  When 
the  ability  of  the  knee  for  carrying  out  its  normal  weight-bearing  func- 
tion is  lessened  by  disease  which  makes  the  parts  sensitive  to  pressure 

and  to  strain,  the  range  of  extreme  mo- 
tion in  both  extension  and  flexion  is 
lessened  and  the  limb  is  persistently 
held  in  flexion  to  a  greater  or  less  degree, 
dependent  upon  the  sensitiveness  of  the 
joint.  The  agents  that  adapt  the  limb 
to  the  habitual  attitudes  are  the  mus- 
cles under  the  control  of  the  nervous 
system.  In  this  sense  the  primary  dis- 
tortions are  due  to  muscular  action,  but 
it  is  certainly  not  true  that  these  muscles 
antagonize  one  another,  and  that  the 
stronger  overcoming  the  weaker  cause 
the  deformity,  since  the  extensors  at  this 
joint  are  stronger  than  the  flexors,  and 
since  flexion  is  the  primary  deformity  at 
every  joint  Avhich  is  diseased  without 
regard  to  the  relative  strength  of  the 
opposing  muscular  groups. 

In  disease  at  the  knee  joint,  as  at  other 
joints,  the  extremes  of  motion  in  every 
direction  that  the  joint  permits  are  limited 
by  muscular  spasm,  but  limitation  of 
extension,  which  is  so  essential  to  nor- 
mal use,  is  at  once  evident,  while  limita- 
tion of  flexion,  the  extremes  of  which 
are  unessential,  is  only  apparent  on  ex- 
amination. Flexion  is  then  the  primary 
distortion  at  the  knee,  and  other  deformities  may  be  classed  as  secondary. 
Secondary  Deformities. — Of  these  the  most  common  is  outward 
rotation  of  the  tibia  upon  the  femur.  When  the  limb  is  fully  extended 
there  is  no  lateral  motion  at  the  knee,  but  when  it  is  flexed  lateral 
motion  is  possible,  and  in  the  attitude  of  flexion  the  traction  of  the 
biceps  upon  the  head  of  the  fibula  tends  to  rotate  it  upon  the  femur. 
This  deformity  is  also  favored  by  the  use  of  the  limb  in  the  attitude 
of  outward  rotation,  which  is  always  assumed  when  the  weakness  or 
stiffness  of  the  knee  joint  is  present,  and  by  the  secondary  knock  knee 
that  often  accompanies  the  disease. 


Tuberculous  disease  of  the  knee  in  an 
adult.    The  synovial  type. 


SYMPTOMS. 


309 


Subluxation  or  backward  displacement  of  the  tibia  upon  the  femur, 
is  another  secondary  deformity.  When  the  leg  is  flexed  upon  the  thigh 
the  articulating  surface  of  the  tibia  glides  backward  upon  the  condyles 
of  the  femur.  Here  it  becomes  fixed  by  muscular  contraction,  and  later, 
by  the  secondary  changes  within  the  joint.  If  muscular  spasm  be  ex- 
treme,   this    alone    might 

cause  the  subluxation,  but  Fig.  221. 

there  are  other  factors;  one 
is  the  destructive  action  of 
the  disease  which  is  usually 
most  marked  at  the  point 
at  which  the  bones  are  in 
contact,  and  the  other  is  the 
leverage  exerted  upon  the 
leg.  This  is  exemplified 
by  the  increase  of  the  dis- 
placement that  is  often 
observed  when  an  attempt 
is  made  to  straighten  the 
limb  by  force,  against  the 
resistance  offered  by  the 
contracted  tissues  on  the 
flexor  aspect.  The  same 
leverage,  in  slighter  de- 
gree, is  exerted  when  the 
weight  of  the  distorted 
limb  is  supported  on  the 
heel  in  the  recumbent  pos- 
ture, or  when  the  limb  is 
extended  in  the  act  of 
walking,  or  if  the  upper 
extremity  of  the  tibia  is 
not  supported  during  the 
period  of  treatment  by 
apparatus. 

Knock  knee  (genu  val- 
gum) is  another  secondary 
deformity.  This  is  ex- 
plained in  certain  instances 
by  the  hypertrophy  of  the 
internal  condyle  caused  by 
disease,  but  it  is  induced 
more  directly  by  the  use  of 

the  flexed  and  somewhat  disabled  limb  in  the  passive  attitude  of  out- 
ward rotation.  Genu  varum  is  uncommon  and  it  is  usually  the  result 
of  the  destruction  of  a  part  of  the  external  condyle  of  the  femur  or 
of  the  tibia. 

The  character  and  the  relative  frequency  of  the  deformities  are  in- 


Untreated  disease  of  the  knee  joint  illustrating  the 
hypertrophy  of  the  condyles  of  tlie  femur,  the  subluxation 
and  outward  rotation  of  the  tibia,  the  atrophy  and  the 
characteristic  deformity. 


310  TUBERCULOUS  DISEASE   OF  THE  KNEE  JOINT. 

dicated  by  the  statistics  from  Koenig's  ^  clinic,  of  1 50  cases  of  knee 
joint  disease  treated  by  arthrectomy,  128  of  these  being  in  children. 
In  94  cases  flexion  was  present;  in  50  from  a  slight  degree  to  135 
degrees  ;  in  16,  from  135  degrees  to  90;  in  28,  to  a  right  angle  or 
less.  Together  with  the  flexion  were  combined  other  deformities  as 
follows  :  Genu  valgum  in  60  cases  ;  moderate  in  42  ;  extreme  in  18. 
Genu  varum  in  1  case.  Subluxation  of  the  tibia  in  20  cases.  Out- 
ward rotation  of  the  tibia  in  10  cases. 

As  has  been  stated,  the  primary  deformity  of  knee  disease  is  simple 
flexion.  If  the  disease  is  of  an  acute  type  this  flexion  increases  rapidly. 
If  it  is  subacute  in  character,  and  especially  if  the  clinical  signs  indi- 
cate that  the  disease  is  primarily  of  the  synovial  membrane,  the  prog- 
ress of  the  deformity  is  slow.  In  ordinary  cases  the  other  deformities 
appear  at  a  later  time  when  the  disease  has  reached  the  destructive 
stage ;  and  they  are  most  marked  in  patients  who  have  persistently 
used  the  deformed  limb  without  protection. 

Actual  Shortening  and  Actual  Lengthening. — Eetardation 
of  growth  is  of  course  not  an  early  symptom  of  disease,  in  fact  actual 
lengthening  of  the  limb,  due  to  the  irritative  effect  of  the  disease  upon 
the  epiphyseal  cartilage  of  the  femur  or  of  the  tibia,  is  common.  This 
lengthening,  sometimes  to  the  extent  of  an  inch  or  even  more,  may 
persist  throughout  the  entire  course  of  treatment,  but  after  the  cure  of 
the  disease  a  corresponding  retardation  of  growth  that  will  more  than 
equalize  the  length  of  the  limbs,  may  be  expected.  And  when  the 
disease  is  of  the  destructive  type,  the  ultimate  shortening  may  be  con- 
siderable, two  or  more  inches  is  not  unusual. 

Leusden,^  in  33  cases  under  treatment  in  the  clinic  at  Gottingen, 
1896-1898,  found  slight  shortening  in  2,  equality  of  length  in  18, 
lengthening  of  the  femur  on  the  diseased  side  in  13. 

116  cases  of  tuberculous  disease  of  the  knee  were  measured  by  Berry 
and  Gibney  ^  with  reference  to  this  point.  In  72  of  these  there  was 
actual  lengthening  of  the  femur,  from  which,  it  may  be  inferred  that 
in  at  least  62  per  cent,  of  the  cases  examined  the  primary  disease  was 
of  the  femur. 

In  17 \  inch. 

"34 \     " 

"  15 1     " 

"     6 1     " 

72 — 62  per  cent. 

Diagnosis. — Tuberculous  disease  is  a  local  destructive  process  that 
is,  as  a  rale,  confined  to  a  single  joint.  This  is  an  important  point  in 
the  differential  diagnosis  from  general  or  constitutional  affections  like 
rheumatism,  rheumatoid  arthritis  and  the  like,  in  which  several  joints 
are  involved.     The  following  conditions  may  be  considered. 

Injury  of  the  Knee. — Strains  of  the  knee  in  childhood  are  often  fol- 
lowed by  limp  and  persistent  flexion  and  pain  on  motion.     In  such 

'Trans.  Am.  Ortli.  Ass'n,  Vol.  XL         2  Deutsche  Zeits.  f.  Chir.,  Bd.  51,  H.  3  and  4. 
3  Am.  Jour.  Med.  Sci.,  Oct.,  1893. 


TREATMENT.  311 

cases  the  onset  is  sudden  and  the  symptoms  usually  disappear  quickly 
under  treatment.  Synovitis  of  traumatic  origin  is  usually  indicative 
of  a  more  severe  injury.  When  synovitis  persists,  the  diagnosis  may 
be  doubtful  because  tuberculous  infection  may  have  followed  the  orig- 
inal injury.  This  emphasizes  the  importance  of  the  careful  treatment 
and  continued  observation  of  injuries  of  this  class,  especially  in  weakly 
children. 

Synovitis. — Chronic  synovitis  of  doubtful  origin,  which  shows  no 
tendency  toward  recovery,  is  usually  tuberculous  in  character. 

Hsemophilia. — Effusion  of  blood  into  the  knee  joint  may  cause  in- 
flammatory symptoms  during  the  stage  of  absorption  and  organization 
of  the  clot,  that  resemble  those  of  disease.  The  sudden  onset  and  the 
personal  history  of  the  patient,  who  may  be  known  as  a  bleeder,  will 
explain  the  symptoms.     (See  page  216.) 

Infectious  Arthritis — Acute  Epiphysitis. — This  is  of  sudden  onset, 
attended  by  the  constitutional  and  local  symptoms  of  suppuration. 

Rheumatism. — This,  in  early  childhood,  may  be  confined  to  a  single 
joint,  but  it  is  of  sudden  onset  and  is  usually  accompanied  by  consti- 
tutional disturbance,  and  after  a  time  other  joints  become  involved. 

Rheumatoid  Arthritis — Osteo-arthritis. — This  affection,  of  the  mon- 
articular form,  is  a  disease  of  adult  life.  It  is  usually  characteristically 
"  rheumatic  "  in  symptoms. 

Charcot's  Disease. — Charcot's  disease  of  the  knee  joint  is  characterized 
by  sudden  effusion,  by  rapid  destruction  of  the  joint  and  consequently 
by  weakness  and  deformity  ;  but  pain  is  usually  very  slight  and  mus- 
cular spasm  is  absent.  The  diagnosis  of  the  disease  of  the  spinal  cord 
will  explain  the  condition  of  the  joint.     (See  page  217.) 

Sarcoma. — Sarcoma,  beginning  in  or  near  the  epiphysis  of  the  femur 
or  of  the  tibia,  may  simulate  tuberculous  disease  very  closely.  If  the 
tumor  is  of  the  periosteal  type,  it  usually  forms  a  more  localized  and 
irregular  swelling  than  could  be  accounted  for  by  tuberculous  disease. 
Central  sarcoma  may  simulate  tuberculosis  very  closely,  but  the  progress 
of  the  tumor  is  more  rapid.  The  clinical  distinction  between  the  two 
is  that  tuberculous  disease  is  very  amenable  to  treatment,  as  far  as  its 
symptoms  are  concerned,  while  the  progress  of  sarcoma  is  but  little 
influenced  by  treatment.  It  may  be  stated,  however,  that  the  X-ray 
is  the  only  means  of  early  diagnosis,  as  the  destruction  of  the  substance 
of  the  bone  about  the  tumor  is  much  greater  than  that  caused  by  tuber- 
culous disease. 

Hysterical  Joint. — Some  of  the  symptoms  of  disease  may  be  simu- 
lated by  hysterical  subjects,  but  there  is  always  an  absence  of  the 
positive  physical  signs  that  invariably  accompany  a  destructive  disease. 

Treatment. — The  treatment  of  tuberculous  disease  of  the  knee  in 
childhood  is  conservative,  operative  intervention  being  simply  inciden- 
tal to  protective  treatment,  while  in  adult  life  the  radical  removal  of 
the  disease  may  be  indicated  as  the  primary  measure. 

The  reasons  for  this  distinction  are  obvious.  In  childhood  the 
duration  of  treatment  is  of  no  particular  importance  as  compared  with 


312 


TUBERCULOUS  DISEASE  OF  THE  KNEE  JOINT. 


the  final  functional  result,  but  in  adult  life  the  shortening  of  the  period 
of  disability  and  the  definite  assurance  of  cure  may  be  of  far  greater 
moinent  than  the  preservation  of  motion. 

Under  favorable  conditions  in  childhood  the  prognosis  of  recovery, 
with  fair  functional  use  of  the  joint,  is  good  ;  while  a  radical  operation, 
although  it  may  cure  the  patient  in  a  shorter  time,  takes  away  the  pos- 
sibility of  a  cure  with  motion.  In  adult  life  a  rigid  limb  is  a  strong, 
useful,  if  somewhat  awkward,  support,  but  in  childhood  the  removal 
of  portions  of  the  epiphyses  and  of  the  epiphyseal  cartilages  entails  a 
progressive  inequality  in  the  limbs,  due  to  loss  of  growth,  and  unless 
the  limb  is  protected  by  mechanical  means,  deformity  is  the  rule,  even 
though  the  disease  has  been  thoroughly  removed.  (Fig.  228.)  Thus 
the  treatment  of  routine  is,  in  childhood,  at  least,  protection ;  protec- 
tion from  the  traumatism  of  motion,  from  the  shock  of  impact  with 
the  ground  and  from  the  pressure  of  muscular  spasm  and  contraction. 

Mechanical  treatment,  which  is  so  difficult  at  the  hip,  is  compara- 
tively easy  at  the  knee  and  as  has  been  stated  the  results  are  correspond- 
ingly better.     At  the  hip  joint  one  of  the  most  common  causes  of 


Fig.  222. 


Extension  and  counter-extension  in  disease  of  the  l;nee  joint.     (Maksh.) 


shortening  and  deformity  is  upward  displacement  of  the  femur  upon 
the  pelvis,  but  at  the  knee,  if  the  limb  is  supported  in  the  attitude  of 
extension,  the  apposition  of  the  broad  surfaces  "of  the  femur  and  the 
tibia,  prevents  displacement,  while  muscular  spasm,  a  symptom  whose 
intensity  is  in  proportion  to  the  degree  of  harmful  motion  that  is  per- 
mitted, is  easily  controlled  by  efficient  splinting. 

Reduction  of  Deformity. — The  first  step  in  treatment  is  the  reduction 
of  deformity  that  may  be  present,  in  order  that  the  limb,  at  the  begin- 
ning as  well  as  throughout  the  entire  course  of  treatment,  may  be  in 
absolutely  normal  position ;  and  as  the  chief  function  of  the  leg  is  to 
support  weight,  the  proper  attitude  is  complete  extension.  Whatever 
motion  the  patient  retains  will  then  be  at  the  point  of  greatest  useful- 
ness. In  the  cases  in  which  an  opportunity  for  reasonably  early  treat- 
ment is  offered,  the  only  deformity  is  flexion,  a  deformity  caused  al- 
most entirely  by  muscular  spasm  ;  although  if  it  has  persisted  for  some 
time  secondary  retraction  of  the  muscles  may  be  present.  In  this  class 
of  cases  the  spasm,  and  consequently  the  deformity,  may  be  readily 
overcome  by  splinting  the  part  while  the  patient  is  confined  to  the  bed. 


TREATMENT. 


313 


The  Plaster  Bandage. — The  most  efficient  splint  is  a  close-fitting^ 
plaster 'bandage,  applied  from  the  groin  to  the  ankle,  or  better,  to  in- 
clude the  foot,  in  order  to  prevent  oedema  of  the  unsupported  part, 
which  is  common  after  the  first  dressing  and  until  the  circulation  of 
the  limb  has  become  adapted  to  the  new  conditions.  In  the  applica- 
tion of  the  bandage  the  bony  prominences  of  the  knee  and  ankle  are 
protected  by  pads  of  cotton.  A  canton  flannel  bandage  is  then  applied 
smoothly,  and  directly  upon  this,  the  light  plaster  bandage.  At  the 
second  application,  at  the  end  of  a  week,  the  subsidence  of  the  spasm 
will  permit  the  straightening  of 

the  limb.     In  cases  of  longer  Fig.;'223. 

standing,  several  successive  ap- 
plications of  the  bandage  may 
be  required,  together  with  man- 
ual extension  during  the  appli- 
cation ;  or  an  ansesthetic  may 
be  administered  which,  reliev- 
ing the  muscular  spasm,  will 
allow  of  immediate  replace- 
ment. Under  anaesthesia  the 
more  resistant  deformities  may 
be  reduced  by  traction  and  by 
slight  leverage,  the  head  of  the 
tibia  being  supported  and 
drawn  forward  by  the  hands, 
as  the  deformity  is  gently  re- 
duced. 

Traction. — Deformity  may 
be  reduced  also  by  traction  with 
the  weight  and  pulley,  the  leg 
being  supported  so  that  no  di- 
rect leverage  is  exerted  at  the 
seat  of  disease.     (Fig.  222.) 

The  Billroth  Spint. — In 
more  resistant  cases  the  Billroth 
splint  as  modified  by  Stillraan, 
may  be  employed.  A  thick 
pad  of  felt  is  placed  over  the 
upper  surface  of  the  condyles  of 

the  femur  and  a  thinner  pad  in  the  popliteal  region  over  the  upper  border 
of  the  tibia.  Other  points  that  may  be  subjected  to  pressure  are  simi- 
larly protected,  especially  the  dorsum  of  the  foot  and  the  perineum.  A 
plaster  bandage  is  then  applied  from  the  groin  to  the  toes,  made  espe- 
cially thick  and  strong  in  the  popliteal  region.  On  either  side  of  the 
knee,  two  curved  slotted  steel  bars  attached  to  expanded  tin  splints  and 
joined  to  one  another  by  an  adjustable  bolt,  are  incorporated  in  it.  (Fig. 
223.)  When  the  bandage  hardens,  it  is  completely  divided  into  two  parts, 
by  a  circular  cut  about  the  knee  and  the  bolts  in  the  slots  are  so  adjusted 


Tuberculous  disease  of  the  knee  in  an  adult, 
with  the  form  of  Billroth  splint  used  at  the  Hos- 
pital for  Paiptured  and  Crippled. 


314 


TUBERCULOUS  DISEASE  OF  THE  KNEE  JOINT. 


Fi(i.   224. 


as  to  form  a  hinged  splint,  the  center  of  motion  being  somewhat  above 
and  in  front  of  the  knee  joint.  When  the  limb  is  slightly  extended,  the 
position  of  the  hinges  has  a  tendency  to  lift  the  tibia  and  to  separate  it 
from  the  femur.  This  straightening  opens  the  cut  in  the  popliteal  re- 
gion, which  is  held  open  by  a  wedge  of  cork.  In  this  manner,  by  the 
insertion  of  larger  wedges,  the  limb  is  gradually  straightened  from  day 
to  day  until  the  deformity  is  overcome,  or  until  a  new  bandage  is  re- 
quired. If  the  pressure  on  the  front  of  the  femur,  when  the  leverage 
is  exerted,  becomes  painful,  a  part  of  the  padding  is  removed. 

Forcible  Correction. — In  very  resistant  cases,  division  of  the 
contracted  parts  by  subcutaneous  or  open  incision,  may  be  required  ; 
or  the  Goldthwait  genuclast  may  be  used.     (Fig.  224.)     The  more 

violent  methods  should  not  be  employed 
during  the  active  stages  of  the  disease; 
and  whenever  considerable  force  is  re- 
quired, in  young  subjects,  the  possibility 
of  separating  the  epiphysis  of  the  femur, 
forcing  it  backward  and  thus  pressing 
upon  the  popliteal  vessels,  should  be 
borne  in  mind. 

Mechanical  Treatment.  —  The  most 
efficient  mechanical  appliance  for  the 
treatment  of  tuberculous  disease  at  the 
knee,  is  the  Thomas  Knee  Brace.  This 
consists  of  two  lateral  uprights  which 
support  the  limb  on  either  side,  termi- 
nating below  the  foot  in  a  crossbar  shod 
with  leather  or  rubber,  which  serves  as 
a  stilt,  and  above  in  a  ring  that  fits  the 
upper  extremity  of  the  thigh,  and  sup- 
ports the  weight  of  the  body.  The  brace 
is  made  of  iron  wire  from  three-six- 
teenths to  three-eighths  of  an  inch  in 
thickness.  The  ring  is  of  an  irregular 
ovoid  shape,  flattened  in  front,  expan- 
ded behind,  and  wider  on  the  inner  than 
on  the  outer  side.  (Fig.  225.)  This 
ring  is  welded  to  the  uprights  at  a  lateral  and  antero-posterior  inclina- 
tion. The  lateral  inclination  forms  an  ansrle  with  the  inner  bar  of  135 
•degrees  (Fig.  227),  the  antero-posterior  inclination  forms  an  anterior 
angle  of  145  degrees  (Fig.  225)  with  the  same  upright,  which  is  set 
upon  the  ring  at  a  point  slightly  in  advance  of  its  fellow.  The  objects 
•of  the  shape  of  the  ring  and  of  its  inclination  are  these  :  its  anterior 
part  is  flat  because  the  surface  of  the  groin  is  flat;  its  posterior  segment 
is  expanded  to  accommodate  the  thickness  of  the  buttock,  the  antero- 
posterior inclination  allows  the  ring  to  rest  comfortably  beneath  the 
tuberosity    of  the  ischium.      The  lateral    inclination  is  made  neces- 


Goldthwait's  genuclast  for  the  correc- 
•tion  of  flexion  deformity  and  subluxation 
at  the  knee. 


sary  by  the  greater  length  of  the  outer  bar  which,  in  order  to  assure 


MECHA  NIC  A  L   TBEA  TMENT. 
Fig.  225.  Fig.  226. 


315 


The  Thomas  knee-splint,  showing  the 
inner  bar,  B,  placed  farther  to  the  front  than 
the  outer  bar  C  ;  A  is  the  lowest  part  of  the 
ring ;  upon  this  rests  the  tuberosity  of  the 
ischium. 


The  ring  of  the  Thomas  knee- 
splint  after  padding.     (Ridlon.) 


Fig.  228. 


Showing  the  front  of  the  ring  of  the 
Thomas  knee  splint. 


Showing  the  back  of  the  ring  of  the 
Thomas  knee  splint.    (Ridlon.) 


316 


TUBERCULOUS  DISEASE   OF  THE  KNEE  JOINT. 


Fig.  229. 


better  support  and  less  pressure,  rises  above  the  level  of  the  trochanter 
major. 

The  ring  is  made  somewhat  larger  than  the  thigh  to  allow  for  pad- 
ding with  felting,  w  hich  should  be  thicker  on  the  inner  and  posterior 
surface,  where  the  weight  is  borne,  than  on  the  anterior  and  outer  part. 
The  padding  is  then  smoothly  covered  with  basil  leather.  As  used  at 
the  Hospital  for  Ruptured  and  Crippled,  the  brace  is  made  from  two 

to  three  inches  longer  than  the  leg,  to 
serve  as  a  stilt  like  the  hip  splint.  To 
the  foot  piece  two  straps  are  attached  on 
either  side  to  provide  for  traction  on  the 
limb  and  for  the  support  of  the  brace.  A 
band  of  leather  is  drawn  between  the 
bars  at  the  upper  third  and  another  at 
the  lower  third  of  the  brace,  to  serve  as 
supports  for  the  thigh  and  calf.  Adhe- 
sive plasters,  reaching  from  the  knee  to 
the  ankle,  provided  with  buckles  above 
the  malleoli,  having  been  applied,  the 
ring  is  pushed  firmly  against  the  per- 
ineum and  is  held  in  position  by  buck- 
ling the  straps  to  the  adhesive  plasters 
with  as  much  traction  as  the  comfort  of 
the  patient  will  permit.  The  thigh  and 
leg  supports  should  fit  the  parts  per- 
fectly; the  knee  is  then  fixed  in  its  place 
by  a  bandage  drawn  tightly  about  it  and 
the  lateral  bars,  and  a  strap  is  applied 
about  the  ankle.  (Fig.  229.)  In  cases  in 
which  the  joint  is  sensitive  and  in  which 
there  is  a  tendency  to  deformity,  the  en- 
tire limb  is  in  addition  enclosed  in  a  light 
plaster  bandage,  so-called  "  skin  fitting,'^ 
applied  directly  upon  a  flannel  bandage. 
If  the  brace  is  attached  by  means  of 
the  adhesive  plaster  straps,  a  certain 
amount  of  traction  is  assured,  together 
with  additional  accuracy  of  adjustment ; 
and  by  the  traction  and  by  the  direct 
pressure  on  the  knee  the  slighter  degrees 
of  deformity  may  be  reduced  without  discomfort.  In  acute  cases  pre- 
liminary rest  in  bed  is  advisable,  and  crutches  may  be  employed  in  the 
early  stages  of  ambulatory  treatment.  But  during  the  greater  part  of 
the  disease  the  splint  serves  as  a  perineal  crutch  and  by  the  use  of  slight 
corrective  force  when  the  plaster  bandages  are  applied,  or  by  traction 
at  times  toward  one  or  the  other  upriglit,  lateral  distortion  of  the  limb 
may  be  corrected  during  the  course  of  treatment.  This  brace  may  be 
used  in  the  treatment  of  very  young  children,  if  it  is  carefully  fitted 


The  TlioLuas  kuoe  brace. 


EXTRA-ARTICVLAB  DISEASE. 


317 


Fig.  230. 


>V 


and  if  the  parts  are  kept  clean  and  dry,  and  it  is  an  effective  brace  for 
ill!  ages?  and  for  all  conditions  of  disease. 

The  Caliper  Brace. — The  traction  may  be  discarded  and  the  brace  may 
be  held  in  position  by  a  shoulder  band,  or  it  may 
be  used  as  a  so-called  caliper  splint.  In  this  form 
it  was  almost  exclusively  employed  by  Mr.  Thomas 
in  his  later  practice  and  at  the  present  time  by 
Hidlon,'  the  long  brace  being  used  simply  for  a 
bed  splint.  As  a  caliper  brace  the  two  bars  are 
cut  off  and  turned  directly  inward  at  a  right 
angle,  are  inserted  into  a  steel  tube  which  is  passed 
through  the  heel  of  the  shoe.  The  bars  are  made 
slightly  longer  than  the  leg  so  that  the  patient's 
heel  is  lifted  nearly  an  inch  from  the  inside  of 
the  shoe  when  walking  ;  thus  the  jar  of  impact 
with  the  ground  is  prevented.  The  brace  is  fixed 
in  position  by  a  leather  band  beneath  the  knee  and 
another  beneath  the  calf,  and  the  limb  is  held  exten- 
ded by  pressure  pads  applied  to  the  thigh  and  leg, 
as  illustrated.  (Fig.  230.)  Ridlon  uses  the  brace 
to  reduce  deformity  by  direct  pressure  backward 
on  the  knee  by  means  of  bandages,  opiates  being 
given  to  relieve  pain. 

Other  braces  may  be  employed,  for  example  the 
traction  hip  splint  (Figs.  203,  204),  but  as  the 
Thomas  brace  answers  every  requirement,  it  seems 
unnecessary  to  describe  others  in  this  connection. 

Treatment  During  Convalescence. — During  the 
active  stage  of  the  disease  the  brace  must  be 
worn  day  and  night ;  during  the  stage  of  recovery 
it  may  be  removed  at  night,  to  allow  for  motion 
at  the  knee,  and  later  a  form  of  walking  brace 
(Fig.  205)  that  will  allow  a  limited  motion  at  the 
knee,  may  be  of  service  ;  but  this  is  not  an  essen- 
tial in  treatment.  If  a  certain  amount  of  knock 
knee  remains  after  recovery,  it  may  be  overcome 
by  the  use  of  a  Thomas  knock  knee  brace  which 
will  also  serve  as  a  protective  splint. 

The  indications  of  cure  have  been  discussed 
under  hip  disease.  In  brief,  when  sufficient  time 
has  elapsed  to  permit  of  natural  cure,  when  there 
has  been  no  symptom  of  active  disease  for  months, 
when  muscular  spasm  has  disappeared,  one  may 
tentatively  remove  the  brace  in  the  manner  de- 
scribed. But  any  symptom  of  disease  and  par- 
ticularly increasing  limitation  of  the  range  of  motion,  or  a  tendency 
toward  deformity,  indicates  the  necessity  for  continued  protection. 

'Trans.  Am.  Orth.  Ass'n,  Vol.  VI. 


The  caliper  splint.  E, 
the  ring  around  the  upper 
part  of  the  thigh  ;  A,  pad 
for  backward  pressure ;  B, 
bandage  ;  C,  bandage ;  F, 
leather  sling  for  support  at 
the  back  of  the  limb ;  D,  a 
strip  of  bandage  fastening 
together  the  pressure  pads 
to  prevent  slipping  and  con- 
sequent loss  of  pressure. 
(Ridlon  and  Jones.) 


318  TUBEBCULOUS  DISEASE  OF  THE  KNEE  JOINT. 

If  anchylosis  be  present,  supervision  and  occasional  treatment  will 
be  required  during  the  period  of  growth  in  order  to  prevent  deformity. 

Extra -Articular  Disease. — In  certain  cases,  especially  in  young  chil- 
dren, the  disease  about  the  epiphyseal  cartilage  of  the  femur  or  of  the 
tibia,  may  find  its  way  to  the  exterior  of  the  bone  before  it  perforates 
the  capsule.  This  is  suggested  by  local  sensitiveness  and  swelling  over 
one  of  the  condyles  of  the  femur  or  about  the  head  of  the  tibia.  In 
such  instances,  the  thorough  removal  of  the  disease  is  indicated,  or  if  a 
Roentgen  picture  shows  that  the  disease  is  accessible,  even  though  it  is 
not  immediately  below  the  surface,  an  exploratory  operation  may  be 
advisable.  In  favorable  cases  prompt  operative  intervention  may  cut 
short  the  course  of  the  disease. 

Aljscess. — Abscess  is  present  as  a  complication  in  about  one-third  of 
the  cases  that  have  received  efficient  protection,  and  in  a  larger  per- 
centage of  the  cases  in  which  treatment  has  been  neglected. 

It  was  present  in  51  per  cent,  of  Koenig's  cases  ^  and  in  47  per  cent, 
of  three  hundred  final  results  reported  by  Gibney."  At  the  knee  as 
at  other  joints,  the  infected  abscess  is  the  most  dangerous  complication 
of  the  disease,  as  is  illustrated  by  Koenig's  statistics. 

Death  rate  in  cases  without  abscess 25  per  cent. 

"         "     "      "         with         "       46  per  cent. 

Although  in  many  instances,  abscess  indicates  an  extensive  and  de- 
structive disease  of  the  bone,  yet  the  exhausting  suppuration  that  is 
an  indirect  cause  of  death,  is  suppuration  from  infected  areas  in  the 
thigh  and  leg,  which  may  have  little  direct  relation  to  the  extent  of 
the  original  disease.  It  should  be  the  aim  in  treatment  to  prevent  this 
burrowing  of  fluid  after  the  capsule  has  been  perforated,  and  to  prevent 
over-distention  of  the  capsule  even,  in  order  to  lesson  the  macerating 
effect  of  the  tuberculous  fluid  upon  the  cartilages.  When  the  fluid  within 
the  capsule  is  of  an  appreciable  amount,  and  when  it  is  increasing  in 
quantity,  it  may  be  removed  by  aspiration ;  or,  a  better  procedure  is  to 
incise  the  capsule.  This  will  allow  a  thorough  removal  of  its  fluid 
and  solid  contents,  after  which  the  opening  may  be  closed  with  sutures. 

Tuberculous  abscess  which  has  perforated  the  capsule  may  be  treated 
in  the  same  manner,  or  it  may  be  drained  subsequently,  according  to 
the  indications.  Unless  the  abscess  is  infected,  careful  bandaging  of 
the  thigh  and  leg  should  prevent  burrowing. 

Synovial  Tuberculosis. — In  the  forms  of  synovial  tuberculosis  that 
resemble  chronic  synovitis  the  fluid  may  be  evacuated  by  an  incision  in 
the  capsule  which  will  allow  for  exploration  and  for  removal  of  the 
fibrinous  masses  that  are  often  present.  Afterwards  the  interior  of 
the  joint  may  be  treated  with  an  application  of  a  strong  solution  of 
chloride  of  zinc,  or  carbolic  acid.  This  sets  up  an  active  inflammation 
which  causes  adhesions  within  the  capsule,  and  exerts  a  favorable  in- 
fluence on  the  course  of  the  disease.     The  injection  of  iodoform  emul- 

1  Trans.  Am.  Orth.  Ass'n,  Vol.  VI.  ^Am.  Jour.  Med.  Sci.,  Oct.,  1893. 


OPERATIVE  TREATMENT.  319 

sion  has  been  extensively  employed  in  the  treatment  of  tuberculosis  of 
the  knese  at  the  Hospital  for  Ruptured  and  Crippled,  but  no  decided 
benefit  has  been  observed.  Theoretically  its  use  should  modify  the  in- 
fectious quality  of  the  tuberculous  fluid,  and  lessen  the  danger  of  in- 
fection with  pyogenic  germs,  and  on  this  ground,  rather  than  because 
it  actually  shortens  the  course  of  the  disease,  it  may  be  recommended. 
(See  Bier's  treatment,  page  203.) 

Arthrectomy. — When,  as  in  exceptional  cases,  the  disease  is  progres- 
sive and  shows  no  tendency  toward  recovery,  and  particularly  if  an 
infected  abscess  communicating  with  the  joint  makes  efficient  drainage 
difficult,  the  operation  of  arthrectomy  may  be  indicated. 

An  Esmarch  bandage  having  been  applied,  the  joint  is  thoroughly 
exposed  by  a  curved  anterior  incision  passing  above  or  below  or 
through  the  patella,  and  all  the  diseased  tissue  is  removed  ;  that  in  the 
soft  parts  is  cut  away,  and  foci  in  the  bone  are  removed  with  the  chisel 
and  scoop.  If  infection  be  present  the  joint  may  be  packed  with  gauze, 
the  leg  being  fixed  in  the  position  of  flexion  ;  but  in  other  instances 
the  wound  is  closed,  with  or  without  drainage  as  may  seem  advisable. 
In  a  large  proportion  of  cases  primary  healing  may  be  obtained.  By 
the  procedure  one  may  hope  to  cure  the  disease,  but  in  all  but  excep- 
tional cases  the  functional  result  will  be  anchylosis.  The  operation 
has  the  advantage  over  excision  in  that  less  bone  is  removed,  and  that 
the  epiphyseal  cartilages,  in  part  at  least,  remain  ;  thus  the  immediate 
as  well  as  the  ultimate  shortening  is  less  than  after  excision. 

Results  of  Arthrectomy. — The  direct  death  rate  of  the  opera- 
tion is  small.  In  150  cases,  reported  by  Koenig,  but  3  deaths  were 
attributable  to  the  operation  itself.  The  final  results  in  1 1 4  of  these  cases, 
in  which  the  operation  was  performed  in  childhood,  were  as  follows  : 

Patients  cured  and  living 90 

Cured  of  the  local  disease  but  not  living 

at  the  time  of  the  investigation 10 

Practically   cured,   insignificant   fistulse 

remaining 2 

102—89. 5  per  cent. 

Living,  not  cured 5 

Deaths  before  the  cure  of  the  local  dis- 
ease      7 

12 — 10. 5  per  cent. 

Thus  in  89  per  cent,  of  the  cases  the  operation  was  successful  as  far 
as  the  cure  of  the  local  disease  was  concerned.  In  75  per  cent,  of  the 
successful  cases,  immediate  cure  was  attained ;  in  25  per  cent,  fistulse 
persisted  for  a  longer  or  shorter  time.  In  10  cases  some  motion  was 
retained,  but  in  the  others  anchylosis  followed  the  operation.  In  about 
70  per  cent,  of  the  cases  the  limb  was  practically  straight ;  in  30  per 
cent,  it  was  distorted.  This  shows  the  necessity  of  continued  super- 
vision during  the  growing  period  of  all  cases  in  which  anchylosis  is 
present  from  whatever  cause. 


:320 


TUBERCULOUS  DISEASE  OF  THE  KNEE  JOINT. 


In  48  cases  in  which  the  operation  had  been  performed  before  the 
tenth  year,  and  iu  which  the  limbs  were  straight,  the  influence  of  the 
operation  on  the  growth  was  investigated. 


Years  elapsed 

Number  of 

Average  Shortening 

since  operatiou. 

cases. 

in  Cm. 

2 

6 

1 

3 

5 

1.6 

4 

4 

1 

5 

3 

2 

6-7 

19 

2 

8-13 

11 

2.5 

These  measurements  indicate  that  the  shortening  is  not  likely  to  be 
very  great  as  a  result  of  the  operation,  certainly  very  much  less  than 
after  complete  or  even  partial  excision,  performed  at  the  same  age. 

Excision. — Excision  of  the  joint 
Fig.  231.  in  childhood   has  been  practically 

abandoned  because  of  the  great 
shortening  that  follows  complete 
removal  of  the  epiphyses,  and  be- 
cause so-called  partial  excision,  that 
is  the  removal  of  thin  sections  of 
bone  from  the  surfaces  of  the 
femur  and  tibia  leaving  the  carti- 
lages, is  usually  an  unnecessary 
operation,  iu  the  sense  that  disease 
that  might  be  cured  by  this  proce- 
dure might  have  been  cured  by 
conservative  methods. 

Early  excision  in  adult  cases  is 
often  indicated  because  it  will  assure 
a  cure  of  the  disease  in  a  short 
time,  whereas  mechanical  treat- 
ment will  require  years  of  dis- 
ability with  no  certain  prospect  of 
absolute  cure  at  the  end  of  the 
period.  If,  therefore,  the  disease 
has  progressed  sufficiently  to  in- 
dicate that  the  natural  cure  would 
result  in  anchylosis,  or  if  the  time 
of  disability  is  of  importance  to  the 
patient,  early  excision  may  be  ad- 
vised in  the  case  of  the  adult,  or 
adolescent,  whose  growth  is  nearly  completed. 

The  operation  is  performed  under  the  Esmarch  bandage,  and  the 
joint  is  exposed  by  the  anterior  incision,  as  in  the  operation  of  arthrec- 
tomy.  All  the  diseased  tissues  are  cut  away  and  sections  of  the  bones, 
parallel  to  the  articular  surfaces,  are  removed,  sufficient  in  depth  to 


Deformity  and  shortening  resulting  from 
excision  of  the  knee  in  childhood. 


PBOGNOSIS.  321 

include  all  the  diseased  area.  If  the  sections  are  so  made  as  to 
allow  the  bones  to  be  brought  into  close  apposition,  sutures  through 
the  periosteum  will  hold  them  in  position,  without  nails  or  wiring. 
The  vessels  having  been  ligated,  the  wound  may  be  closed  with 
or  without  drainage,  as  may  be  indicated,  a  plaster  of  Paris  dressing- 
is  applied,  and  the  limb  is  elevated.  Mechanical  support  is  of 
service  in  the  after-treatment  in  lessening  the  discomfort  and  hasten- 
ing the  cure. 

Kesults  of  Excision. — In  Koenig's  statistics  of  three  hundred 
excisions,  6  deaths  were  due  directly  to  the  operation,  and  23  others 
occurred  during  the  course  of  after-treatment;  a  total  of  29  (9.6  per 
cent.). 

In  23  instances  amputation  was  afterwards  performed  because  of 
failure  of  the  operation.  The  good  results  are  classed  by  Koenig  as 
75  per  cent.,  the  bad  as  25  per  cent.  In  193  cases,  the  position  of 
the  limb  in  after  years  was  investigated.  It  was  straight  in  175,  dis- 
torted in  18  ;  all  but  one  of  this  latter  group  being  in  children. 

Amputation. — This  operation  is  indicated  as  a  life-saving  measure. 
When  the  disease  is  so  extensive  as  to  require  complete  removal  of 
the  epiphyses,  in  early  childhood,  amputation  is  the  preferable  opera- 
tion, as  the  limb,  aside  from  requiring  constant  protection  to  prevent 
deformity,  will  be  so  short  as  to  be  of  little  practical  use. 

Operations  for  the  Eelief  of  Final  Deformity. — If  the  joint  is  anchy- 
losed  in  an  attitude  of  marked  flexion,  the  limb  may  be  straightened 
by  the  removal  of  a  sufficient  wedge  of  bone  from  the  joint.  Slighter 
degrees  of  flexion  may  be  remedied  by  linear  osteotomy  of  the  femur. 

Genu  valgum  may  be  corrected  by  a  similar  operation. 

Prognosis. — The  most  important  statistical  evidence  on  the  course 
and  the  outcome  of  tuberculous  disease  of  the  knee  joint  in  childhood, 
has  been  presented  by  Gibney.  The  statistics  completed  in  1892  were 
the  result  of  an  investigation  of  four  hundred  and  ninety-nine  cases 
treated  during  a  period  of  twenty  years,  1868-1887.  In  but  three 
hundred  of  these  could  definite  information  be  obtained.^ 

Eighty-seven  per  cent,  of  the  cases  were  in  children,  and  51  per 
cent,  of  the  patients  were  less  than  five  years  of  age  at  the  inception  of 
the  disease. 

The  cases  were  divided  into  three  classes,  according  to  the  treatment 
that  had  been  followed  : 

1.  The  expectant  treatment.  In  this  class  no  apparatus  was  em- 
ployed or,  if  employed,  it  was  inefficiently  used. 

2.  The  fixation  treatment.  In  this  class  the  joint  was  more  or  less 
efficiently  splinted,  but  not  protected  from  impact  Avith  the  ground. 

3.  The  protective  treatment.  In  this  class  the  joint  was  both 
splinted  and  protected  from  jar,  and  the  mechanical  treatment  was  effi- 
cient. 

1  Am.  Jour.  Med.  Sci.,  October,  1893. 
21 


322  TUBERCULOUS  DISEASE  OF  THE  KNEE  JOINT. 

The  results  were  classified  as  follows  : 


M 

o 

a 

a 

a 

* 

'm 

3 

ja 

s  S 

-B 

a 

s 

a 

fl*2 

£ 

H 

W 

< 

« 

& 

o 

Expectant 

71 

5 

3 

3 

9 

51 

190 
39 

9 

0 

1 
0 

35 

2 

31 
11 

114 

26 

300 

14 

4 

40 

51 

191 

Mortality. — The  total  deaths  in  the  300  cases  were  40  (13.3  per 
cent.);  26  of  these  were  from  causes  directly  or  indirectly  connected 
with  the  disease  (8.6  per  cent.),  viz.  : 

Operative  shock 1 

Prolonged,  suppuration 16 

Tuberculous  meningitis 6 

Phthisis ._3 

26 
Intercurrent  diseases 14 

40 

Function. — The  functional  results,  as  regards  motion,  in  the  cases 
in  which  conservative  treatment  was  continued  to  the  end,  including 
the  cases  still  under  observation,  242  of  300,  were  as  follows  : 


Expectant 
Fixation... 
Protection 


Total. 

Motion  retained. 

Anchy- 
losed. 

60 
145 

37 

44  or    7  per  cent. 

113    "77        " 
34    "95 

16 

32 

3 

242 

191    "  79 

51 

Of  the  191  patients  who  retained  a  movable  joint  74  had  had  ab- 
scess, 3  or  more  cicatrices  being  present  in  39. 

f\  I  As  to  the  range  of  motion  in  74  it  was  from  45  degrees  to  normal 
and  in  41  more  than  90  degrees,  thus  30  per  cent,  of  the  patients  re- 
tained a  fair  range  of  motion. 

Deformity. — In  51  cases  anchylosis  was  present,  in  16  of  these  the 
limb  was  practically  straight,  in  35  it  was  flexed  more  than  30  degrees 
(69  per  cent.). 

These  statistics  again  illustrate  the  great  tendency  toward  deformity, 
when  during  the  growing  period  there  is  anchylosis  at  the  knee  from 
whatever  cause. 

In  the  191  cases  in  which  motion  was  retained  the  limb  was  prac- 
tically straight  in  125  (65  per  cent.).  In  49  others  the  flexion  was 
less  than  25  degrees  and  in  but  16  could  the  deformity  be  classed^  as 
bad  (8  per  cent.). 

In  10  cases  only  did  relapse  occur  after  apparent  cure. 

In  but  16  of  the  449  cases  was  there  involvement  of  other  joints 


GENERAL   CONCLUSIONS.  323 

while  the  patients  were  under  observation  (3.2  per  cent.).  In  8  of 
these  the  spine  was  involved,  in  2,  the  hip,  and  in  6  other  joints. 

The  influence  of  age  upon  the  death  rate,  and  the  ultimate  causes  of 
death,  are  illustrated  by  Koenig's  statistics,  the  death  rate  being  much 
higher,  at  least  in  the  cases  in  early  childhood,  than  in  this  country. 

According  to  Koenig's  statistics,  the  death  rate,  direct  and  indirect, 
from  disease  of  the  knee  joint,  was  as  follows  : 

323  children  (1  to  15  years  of  age),       deaths  65  (20  per  cent.) 

225  patients  (16  to  30  years  of  age),  "      61  (24  per  cent.) 

68         "       (31  to  40  years  of  age),  "      30  (44  per  cent.) 

74        "        more  than  40  years  of  age     "      45  (60  per  cent.) 

Causes  of  Death. 

Deaths  from  causes  not  connected  with  the  disease,  14  (2  per  cent.). 
Deaths  following  operations,  18  (2,5  per  cent.). 

Deaths  caused  by  tuberculosis,  141  (22.5  per  cent,  of  all  cases  and  80  per 
cent,  of  all  the  deaths). 

Tuberculosis  of  the  knee 1 

Tuberculosis  of  the  lungs 94 

General  tuberculosis 30 

Tuberculous  meningitis 7 

Acute  miliary  tuberculosis 3 

Tuberculosis  of  other  parts 6 

141 

It  may  be  noted  that  16  of  the  40  deaths  in  Gibney's  cases  were  due 
to  prolonged  suppuration,  and  that  of  51  cases  still  under  observation 
26  had  been  treated  for  ten  years  or  longer,  and  were  still  uncured. 
This  indicates,  that  in  a  larger  proportion  of  the  cases  conservative 
methods  should  have  been  supplemented  by  more  radical  treatment. 
Still,  taken  as  a  whole,  the  results,  although  the  mechanical  treatment 
was,  in  many  instances,  far  from  efficient,  are  much  better  than  any 
others  that  have  been  presented. 

General  Conclusions. — On  this  evidence  the  following  conclusions 
seem  to  be  justified.  The  death  rate  in  childhood  from  all  causes 
should  be  less  than  10  per  cent.  The  duration  of  treatment  is  from  2 
to  5  years.  Recovery  with  a  useful  range  of  motion,  when  the  diagnosis 
has  been  made  at  an  early  stage  and  when  efficient  mechanical  treat- 
ment has  been  employed,  may  be  predicted  in  50  per  cent,  of  the  cases. 

Deformity  can  always  be  prevented  by  treatment  and  by  super- 
vision. Under  favorable  conditions,  radical  operations  are  not  often 
indicated,  but  when  indicated,  they  should  not  be  delayed  too  long. 
Amputation  of  the  limb  should  prevent  death  from  prolonged  suppura- 
tion. In  a  certain  proportion  of  cases  the  disease  may  be  cut  short  by 
early  exploratory  operations,  for  the  removal  of  foci  of  disease  in  the 
bone  before  the  joint  has  become  involved. 

Although  the  benefits  of  protective  treatment  are  as  evident  in  dis- 
ease of  the  adult  as  in  childhood,  yet  early  operation  is  often  indicated 
in  this  class,  because  of  the  necessity  for  shortening  the  period  of  dis- 
ability, and  because  excision  assures  a  straight  and  useful  limb. 


CHAPTER    X. 

NON-TUBERCULOUS  AFFECTIONS  AND  DEFORMITIES 
OF    THE   KNEE   JOINT. 

Strains  and  Injuries  of  the  Knee  in  Childhood. 

Injury  of  the  knee  in  childhood  may  cause  local  discomfort  and 
persistent  flexion  of  the  leg,  even  when  but  little  synovial  effusion  is 
present.  In  this  class  of  cases  the  application  of  a  plaster  bandage  is 
of  service  in  resting  the  part  and  preventing  further  injury.  The 
importance  of  treating  promptly  slight  injuries  of  the  joints  in  child- 
hood, especially  in  the  class  of  patients  predisposed  to  tuberculous 
infection,  has  been  mentioned  already  in  the  consideration  of  hip 
disease. 

Synovitis. 

Acute  traumatic  synovitis  is  properly  treated,  immediately  after  the 
injury,  by  splints,  by  elevation  of  the  limb,  by  the  application  of  ice 
bags  and  the  like ;  but  after  the  acute  symptoms  have  subsided  the 
absorption  of  the  effused  fluid  is  aided  by  functional  use  of  the  limb, 
if  the  joint  is  properly  protected.  One  of  the  most  efficient  methods 
of  treatment  is  that  by  means  of  the  adhesive  plaster  strapping,  advo- 
cated by  Cottrell  and  Gibney.  The  entire  surface  of  the  knee,  except 
a  narrow  space  in  the  popliteal  region,  is  firmly  strapped  with  over- 
lapping layers  of  adhesive  plaster,  extending  from  the  upper  third  of 
the  leg  to  the  middle  third  of  the  thigh  ;  and  over  this  a  flannel  band- 
age is  applied ;  or  if  the  leg  is  swollen,  the  entire  limb  should  be 
firmly  bandaged  with  elastic  stockinette  bandage,  from  the  toes  to  the 
upper  third  of  the  thigh  in  addition.  (Fig.  238.)  The  adhesive  plaster 
serves  as  a  support  which  allows  a  certain  degree  of  motion,  sufficient 
to  stimulate  the  circulation,  and  thus  to  hasten  the  restoration  of  the  nor- 
mal condition.  If  greater  compression  is  desired,  the  entire  joint  may 
be  covered  with  the  adhesive  plaster  as  suggested  by  Hoffmann.^  A 
pad  of  cotton  is  placed  in  the  popliteal  space,  a  close-fitting  stocking 
leg  is  drawn  over  the  knee  and  about  this  circular  bands  of  plaster  are 
drawn  as  tightly  as  the  comfort  of  the  patient  will  permit.  The  adhe- 
sive plaster  strapping  is  renewed  from  time  to  time,  as  the  swelling 
diminishes  and  its  use  is  continued  until  the  symptoms  have  entirely 
disappeared. 

Chronic  synovitis  may  be  treated  in  a  similar  manner,  although  if 

IN.  Y.  Med.  Jour.,  January  27,  1900. 


PREPATELLAR  BURSITIS.  325 

the  eifusion  is  persistent  the  fluid  may  be  removed  by  aspiration.  If 
the  liga!ments  are  lax,  a  supporting  brace  may  be  required  for  a  time 
(Fig.  152),  and  massage  and  exercises  are  of  service  in  the  stage  of 
recovery. 

Infectious  Arthritis. 

Suppurative  arthritis  in  this,  as  in  other  joints,  should  be  treated  by 
free  incisions,  and  efficient  drainage  should  be  assured.  Under  proper 
treatment  practically  perfect  recovery  is  not  unusual.  Mechanical 
protection  is  usually  required  after  the  immediate  svmptoms  are  relieved. 
(See  page  208.) 

RHEUMATOID    ARTHRITIS. 
Osteo-Arthritis. 

In  this  disease  several  joints  are  usually  involved,  but  occasionally 
the  affection  may  be  confined  to  the  knee.  The  early  symptoms  are 
stiffness,  discomfort  and  pain  more  noticeable  in  damp  weather,  and 
often  creaking  sensations  in  the  joint  are  appreciable  to  the  patient. 
At  intervals  the  symptoms  may  be  more  acute  and  the  joint  becomes 
hot  and  swollen,  as  in  rheumatism ;  as  a  rule,  however,  they  are  sub- 
acute in  character.  The  progress  of  the  affection  is  slow,  the  joint 
becomes  somewhat  enlarged  and  irregular  in  outline,  the  range  of 
motion  becomes  more  restricted,  and  flexion  of  the  limb,  after  a  time, 
persists.     (See  page  212.) 

Treatment. — The  general  and  constitutional  treatment  of  rheuma- 
toid arthritis  does  not  require  especial  consideration  here.  Locally, 
massage  and  the  hot-air  bath,  may  add  to  the  comfort  of  the  patient 
and  increase  the  mobility  of  the  joint,  in  the  early  stage  of  the  affec- 
tion, at  least.  Static  electricity  has  been  employed  with  advantage 
in  certain  cases.  The  application  of  the  cautery  and  stimulating  lini- 
ments are  useful  in  relieving  pain,  and  the  support  of  a  flannel  band- 
age adds  much  to  the  comfort  of  the  patient. 

Prepatellar  Bursitis. 

Synonym. — Housemaid's  Knee. 

A  chronic  enlargement  of  the  bursa  lying  over  the  patella  and  its 
ligament,  is  common  among  those  who  have  to  kneel  much  of  the 
time,  hence  the  popular  name.  Occasionally  cases  of  acute  bursitis,  in 
which  there  is  considerable  effusion  into  the  sac,  are  seen,  and  these 
are  sometimes  mistaken  for  synovitis  of  the  knee. 

Treatment. — In  acute  cases,  strapping  the  front  of  the  knee  with 
strips  of  adhesive  plaster  which  will  limit  motion  and  provide  compres- 
sion, is  an  effective  treatment.  If  the  effusion  is  considerable,  it  may 
be  relieved  by  aspiration.  In  chronic  cases,  cure  can  be  attained  only 
by  the  removal  of  the  thickened  sac. 


326    NON-TUBERCULOUS  AFFECTIONS  OF  THE  KNEE  JOINT. 

Pretibial  Bursitis. 

Beneath  the  ligamentum  patellae,  occupying  the  space  between  the 
tendon  and  the  periosteum  of  the  tibia,  is  the  deep  pretibial  bursa.  It 
is,  according  to  the  investigations  of  Lovett,^  as  wide  or  somewhat 
wider  than  the  tendon  ;  its  upper  border  is  on  a  level  with  the  joint,  its 
lower  border  reaches  to  the  twbercle  of  the  tibia,  and  being  slightly 
longer  on  the  outer  than  on  the  inner  border,  it  is  somewhat  triangular 
in  shape.     It  does  not  communicate  with  the  knee  joint. 

Enlargement  of  this  bursa  is,  as  a  rule,  the  result  of  injury,  but,  as 
bursitis  elsewhere,  it  may  be  a  complication  of  infectious  disease,  rheu- 
matism and  the  like. 

Symptoms. — The  symptoms  are  stiffness  at  the  knee  and  pain  on 
sudden  movement,  especially  when  strain  is  exerted  on  the  tendon  by 
complete  flexion  or  extension  of  the  leg  as  in  active  use.  The  tubercle 
of  the  tibia  seems  enlarged  and  is  sensitive  to  pressure,  and  a  swelling 
on  either  side  of  the  ligament  is  usually  evident. 

Treatment. — The  aifection,  if  at  all  acute,  may  be  treated  by  re- 
lieving the  strain  and  pressure  on  the  tendon,  by  fixation  of  the  limb 
for  a  time  in  a  plaster  bandage,  or  other  form  of  splint.  Later,  the 
adhesive  plaster  strapping  will  provide  sufficient  fixation  and  pressure. 
The  absorption  of  the  fluid  may  be  hastened  by  the  application  of  the 
cautery.  If  the  swelling  is  persistent,  the  fluid  may  be  removed  by  aspi- 
ration or  incision  of  the  sac.    Its  complete  removal  is  not  often  necessary. 

Enlargement  of  the  Superficial  Pretibial  Bursa. 

A  small  bursa,  lying  upon  the  insertion  of  the  ligamentum  patellae, 
may  become  enlarged,  causing  an  aj)parent  hypertrophy  of  the  tubercle  of 
the  tibia.  It  may  be  treated  by  strapping  with  adhesive  plaster,  and  the 
prominent  tubercle  should  be  protected  by  some  form  of  bunion  plaster. 

Bursas  and  Cysts  in  the  Popliteal  Region. 

Simple  inflammation  of  the  bursa  lying  between  the  inner  head  of 
the  gastrocnemius  and  the  semimembranosus  muscle,  may  cause  a 
fluctuating  swelling  on  the  inner  side  of  the  popliteal  region.  Cysts 
in  the  popliteal  region  usually  communicate  with  the  knee  joint  and 
are  complications  of  rheumatic  or  tuberculous  disease.  They  are  of 
interest  principally  from  the  diagnostic  standpoint. 

Internal  Derangement  of  the  Knee  Joint.     (Hey.) 

The  term  internal  derangement  signifies  sudden  interference  with 
the  function  of  the  joint  which  may  be  due  to  :  (a)  Loose  bodies  in 
the  joint ;  (6)  Displacement  of  a  semilunar  cartilage  ;  (c)  Other  injury.^ 

Loose  Bodies  in  the  Knee  Joint. — Loose  bodies  in  the  knee 
joint  may  be  composed  of  portions  of  fibrin,  fragments  of  synovial  mem- 

'  Boston  City  Plospital  Reports,  Eighth  Series,  1897. 
2  W.  H.  Bennett,  Lancet,  Jan.  6,  1900. 


INTERNAL  DERANGEMENT  OF  THE  KNEE  JOINT.  327 

brane  or  bits  of  cartilage  or  bone  and  the  like.  In  certain  forms  of 
synovial  tuberculosis  and  osteo-arthritis,  these  loose  bodies  may  be 
present  in  large  numbers,  but  from  the  therapeutic  standpoint  the 
important  cases  are  those  in  which  the  joint  is  otherwise  normal.  In 
this  class  the  foreign  body  is  sometimes  detected  by  the  patient  as  a 
smooth,  movable  object  on  one  or  the  other  side  of  the  patella  ;  but  in 
many  instances  the  first  sign  of  its  presence  is  interference  with  the 
function  of  the  joint.  After  a  sudden  movement  or  when  the  knee 
has  been  flexed,  as  in  the  kneeling  position,  or  without  appreciable 
cause,  severe  pain  in  the  knee  is  felt  and  the  joint  may  be  fixed  in  the 
position  of  flexion.  By  massage,  manipulation,  or  spontaneously,  the 
foreign  body  is  dislodged  from  between  the  surfaces  of  the  bones  and 
movement  becomes  free  and  painless,  but  discomfort  remains  for  a 
time  and  in  most  instances  synovial  effusion  follows.  These  symptoms 
recur  at  intervals  and  the  disappearance  of  the  movable  body  from  its 
accustomed  place  at  such  times  demonstrates  its  relation  to  the  dis- 
ability. 

Displacement  of  a  Semilunar  Cartilage. — Displacement  of 
a  semilunar  cartilage  is  usually  of  traumatic  origin,  and  it  appears  to 
be  caused  most  often  by  an  outward  twist  of  the  tibia  upon  the  femur. 
The  patient's  limb  is  fixed  in  the  attitude  of  flexion,  and  in  certain 
instances  an  irregularity  may  be  detected  at  the  inner  and  upper  border 
of  the  tibia. 

To  replace  the  cartilage,  the  leg  should  be  flexed  then  suddenly  ex- 
tended and  rotated  inward.  In  some  instances  an  ansesthetic  may  be 
required.  The  displacement  is  followed  by  discomfort  and  synovial 
effusion,  and  the  accident  having  once  occurred,  is  likely  to  recur ;  the 
patient  recognizing  the  character  of  the  movements  that  are  likely  to 
cause  the  displacement,  also  the  proper  manipulation  for  its  replacement. 

Injury. — In  other  instances,  somewhat  similar  symptoms  may  fol- 
low injury  at  the  knee,  pinching  of  the  synovial  membrane,  bruising 
of  the  cartilage  or  a  strain  of  one  of  the  ligaments  within  the  joint, 
being  assigned  as  causes.  In  cases  of  this  character  in  which  the  symp- 
toms recur  from  time  to  time,  the  joint  becomes  weak  and  insecure, 
partly  because  of  the  repeated  synovial  effusions  and  partly  because  of 
the  muscular  relaxation. 

Treatment. — Immediately  after  the  displacement  or  injury,  the  -oint 
should  be  splinted  for  a  time,  afterwards  it  may  be  protected  by  the  ad- 
hesive plaster  strapping,  and  when  the  effusion  has  been  absorbed  mas- 
sage and  exercises  for  strengthening  the  muscles  should  be  employed. 

In  the  more  chronic  cases  in  which  the  ligaments  are  lax,  a  brace 
which  will  permit  antero-posterior  motion,  but  prevent  lateral  mo- 
bility, may  be  required.  The  Campbell  brace  (Fig.  152)  used  by 
Shaffer,  is  a  light  and  effective  support  that  interferes  little,  if  at  all, 
with  the  use  of  the  limb.  If  the  diagnosis  of  displaced  cartilage  can 
be  verified,  and  if  it  is  the  cause  of  persistent  disability,  it  should  be 
removed.  And  the  same  may  be  said  of  isolated  foreign  bodies,  which 
are  known  to  be  the  cause  of  the  symptoms. 


328    NON-TUBERCULOUS  AFFECTIONS   OF  THE  KNEE  JOINT. 

Congenital  Genu  Recurvatum. 

Synonym. — Anterior  Displacement  of  the  Tibia. 

Tlie  most  common  of  the  congenital  deformities  at  the  knee  is  the 
so-called  genu  recurvatum,  in  which  the  knee  is  bent  somewhat  back- 
ward, or  in  other  words,  the  leg  is  hyper-extended  on  the  thigh.  The 
condition  is  often  spoken  of  as  an  anterior  dislocation,  but  there  is  no 
actual  displacement,  except  in  the  extreme  cases  in  which  the  tibia 
may  be  turned  directly  forward  on  the  femur,  even  to  a  right  angle 
or  less.  In  the  ordinary  cases  the  range  of  extension  is  merely  ex- 
aggerated, while  flexion  is  limited  or  checked,  principally  by  adaptive 
shortening  of  the  quadriceps  extensor  muscle.        (Fig-  232.) 

The  appearance  in  well-marked  genu  recurvatum  is  very  peculiar,  it 
is  as  if  the  patient's  leg  were  reversed,  for  the  popliteal  depression  has 

Fig.  232. 


ConjjLiiitil  5,(  iiu  recurvatum.     (Hoffa.) 


become  a  prominence  and  the  range  of  over-extension  seems  to  repre- 
sent normal  flexion.  In  such  cases  the  leg  may  be  brought  to  the 
straight  line,  but  greater  flexion  is  resisted  by  the  retracted  tissues,  and 
when  the  pressure  of  the  hand  is  removed  the  leg  is  drawn  back  to  the 
deformed  position  by  the  contraction  of  the  quadriceps  extensor  muscle. 

Other  Deformities  and  Malformations. — Genu  recurvatum 
is  not  infrequently  accompanied  by  varus  or  valgus  deformity  at  the 
knee,  more  often  by  the  latter,  and  by  laxity  of  the  ligaments.  In 
many  instances  the  patella  is  absent  or  is  rudimentary  and  not  infre- 
quently the  deformity  is  accompanied  by  malformations  or  defective 
development  of  other  parts. 

Seventy-eight  cases  were  collected  by  Potel.^  In  thirty-seven  in- 
stances the  deformity  was  limited  to  one  side,  in  the  others  both  legs 

^  Etude  sur  les  Malformations  Congenitale  du  Genoa.  Lille,  1897,  Imp.  L.  Danel. 


CONGENITAL  DISPLACEMENT  OF  THE  PATELLA.  329 

were  affected.  In  fiftv  cases  the  condition  of  the  patella  was  noted,  in 
twenty-Six  of  these  it  was  absent  or  rudimentary.  Twenty  of  the  cases 
were  accompanied  by  talipes. 

Etiolog"y. — The  deformity  in  cases  of  simple  recurvatnm  may  be 
explained  by  an  abnormal  and  fixed  position  in  utero,  and  in  cases  seen 
soon  after  birth  the  mechanism  is  clearly  shown  by  the  habitual  atti- 
tude. The  thighs  are  sharply  flexed  on  the  body,  the  dorsal  surfaces 
of  the  hyper-extended  knees  are  in  relation  to  the  abdomen,  while  the 
feet  may  be  brought  into  contact  with  the  face  or  trunk,  according  to 
the  degree  of  deformity.  The  retarded  development  of  the  quadriceps 
extensor  muscle  explains  the  rudimentary  patella  which  is  often  an  ac- 
companiment of  the  deformity. 

Treatment. — The  treatment  of  the  hyper-extended  knee  is  very  sim- 
ple. It  consists  in  massage  of  the  atrophied  and  contracted  muscle, 
combined  with  more  or  less  forcible  manipulation  in  the  direction  of 
flexion.  If,  as  is  often  the  case,  the  leg  seems  to  be  drawn  forward  by 
spasmodic  muscular  action,  the  methodical  massage  should  be  combined 
with  the  use  of  a  simple  posterior  splint. 

In  the  more  extreme  cases  manual  force  may  be  applied  under  anses- 
thesia,  and  the  deformity  may  be  overcome  at  one  or  several  sittings, 
according  to  the  resistance  of  the  contracted  parts.  The  leg  is  then 
fixed  in  a  flexed  position  until  the  tendency  to  recurrence  has  been 
overcome.  When  the  child  begins  to  walk,  a  light  lateral  brace  may 
be  necessary  to  insure  perfect  functional  use  of  the  joint,  as  in  many 
instances  laxity  of  ligaments  and  muscular  weakness  may  persist  for  a 
long  time. 

Rudimentary  or  Absent   Patella. 

As  has  been  stated,  a  rudimentary  patella  is  a  frequent  complication 
of  genu  recurvatum,  or  of  any  congenital  defect  or  deformity  of  the 
knee,  or  limb  that  involves  imperfect  development  of  the  quadriceps 
extensor  muscle.  In  many  cases  of  this  type  it  is  impossible  to  dis- 
tinguish the  patella  during  the  early  months  of  infancy,  but  later,  a 
minute  patella  appears  that  slowly  increases  to  an  approximately  nor- 
mal size. 

Absence  of  patella  under  the  same  conditions  is  less  frequent,  al- 
though Potel  collected  one  hundred  cases  from  literature. 

Treatment. — The  treatment  of  rudimentary  patella  is  included  in 
the  massage  and  stimulation  of  the  atrophied  or  rudimentary  muscle 
with  which  it  is  usually  associated,  and  the  support  that  the  weak  or 
deformed  knee  may  require. 

Congenital  Displacement  of  the  Patella. 

The  patella  may  be  displaced  upward  as  a  result  of  extreme  genu 
recurvatum,  and  in  rare  instances  it  may  be  displaced  inward  or  down- 
ward, but  far  more  often  the  displacement  is  outward.  Fifty  cases 
of  this  form  are  recorded,  in  most  of  which  it  was  a  complication  of 
congenital  genu  valgum. 


330     NON-TUBERCULOUS  AFFECTIONS  OF  THE  KNEE  JOINT, 

Slipping  Patella. 

This  term  is  applied  to  an  abnormal  laxity  of  the  supporting  tissues 
that  allows  intermittent  displacement  of  the  patella  upon,  or  to  the 
outer  side  of,  the  external  condyle. 

Etiology. — The  disability  is  more  common  among  females  than 
males  and  is  more  often  unilateral  than  bilateral.  The  abnormal  mo- 
bility may  be  an  inherited  peculiarity ;  it  may  be  due  to  weakness  of 
the  quadriceps  extensor  muscle,  or  to  imperfect  development  of  the 
patella  or  of  the  external  condyle ;  or  the  original  displacement  may 
have  been  due  to  injury.  In  many  instances,  however,  the  predispos- 
ing cause  is  genu  valgum,  as  a  consequence  of  which  the  patella  is  car- 
ried toward  the  external  condyle. 

Symptoms. — If  the  slipping  of  the  patella  is  a  frequent  occurrence 
it  causes  comparatively  little  pain,  but  when  the  parts  are  less  relaxed 
the  displacement  is  likely  to  be  followed  by  a  certain  amount  of  effu- 
sion into  the  joint  and  by  the  symptoms  of  a  sprain.  It  is  usually  the- 
result  of  a  misstep  or  sudden  movement  when  the  thigh  muscle  is  re- 
laxed or  of  extreme  flexion  of  the  leg.  As  a  rule  there  is  a  sense  of 
insecurity  and  weakness  at  the  knee  in  those  who  are  subject  to  the 
accident. 

Treatment. — The  treatment  varies  according  to  the  condition  of  the 
parts  about  the  joint.  If  the  displacement  is  the  direct  result  of  vio- 
lence the  leg  should  be  fixed  for  a  time  in  a  plaster  bandage,  which 
may  be  replaced  by  the  adhesive  plaster  strapping  or  a  knee  cap.. 
Later  massage  and  muscle  training  should  be  employed.  In  cases  in 
which  the  slipping  has  become  habitual  and  particularly  when  the  liga- 
ments of  the  joint  are  much  relaxed,  a  liglit  leg  brace  should  be  em- 
ployed to  prevent  lateral  motion  and  to  limit  the  range  of  flexion  at 
the  joint,  if  this  predisposes  to  the  displacement. 

Operative  Treatment. — If  the  position  of  the  patella  that  predisposes 
to  the  further  displacement  is  a  consequence  of  genu  valgum  the  recti- 
fication of  the  deformity  will,  as  a  rule,  remedy  the  secondary  disabil- 
ity. If  the  displacement  appears  to  be  caused  by  laxity  of  the  capsu- 
lar ligament,  as  well  as  by  the  abnormal  position  of  the  patella,  an 
operation  for  the  purpose  of  limiting  the  mobility  and  restoring  the 
proper  relation  of  parts  may  be  conducted  in  the  following  manner  : 
A  long  curved  incision  is  made  about  the  inner  side  of  the  knee,  the 
lower  extremity  of  which  crosses  the  ligamentum  patellae.  The  skin 
flap  having  been  reflected  the  capsule  may  be  divided  on  the  outer  side 
without  disturbing  the  synovial  membrane.  The  patella  is  then  forced 
forward  and  the  redundant  tissue  on  the  inner  side  is  folded  and  sutured, 
or  a  section  of  the  capsule  may  be  removed,  sufficient  in  size  to  hold 
the  patella  in  its  proper  position.  In  extreme  cases  the  tubercle  of 
the  tibia,  with  the  attached  tendon,  may  be  removed  and  reimplanted 
on  the  inner  aspect  of  the  tibia,  as  performed  by  Wolff  and  Walsham. 

The  limb  should  be  held  in  the  extended  position  for  a  time,  and 
it  should  afterwards  be  supported  by  a  brace  or  knee  cap  for  several 


SNAPPING  KNEE.  331 

months.  Subsequently  massage,  and  exercise  of  the  weakened  muscle 
will  be  df  advantage. 

The  operation  for  the  dislocated  patella  has  been  performed  in  child- 
hood by  Pollard/  and  in  early  infancy  by  Bajardi.^ 

The  method  described  is  that  of  Bradford.^ 

Elongation  of  the  Ligamentum  Patellae. 

In  certain  cases  the  ligamentum  patellae  may  be  abnormally  long  so 
that  the  patella  lies  habitually  above  its  proper  position.  This  elonga- 
tion may  be  one  of  the  evidences  of  general  relaxation  of  the  liga- 
ments of  the  knee,  and  thus  a  predisposing  cause  of  the  slipping  pa- 
tella, or  of  abnormal  mobility  at  the  knee  joint. 

Etiology. — The  elongation  of  the  tendon  may  be  a  congenital  pecu- 
liarity or  it  may  be  acquired.  It  is  often  observed  as  an  eifect  of  an- 
terior poliomyelitis,  or  of  hemi-  or  paraplegia. 

Symptoms. — The  symptoms  of  elongation  of  the  ligamentum  patel- 
lae, as  distinct  from  those  of  the  general  laxity  of  the  ligaments,  that 
is  often  present,  are  weakness  and  disability,  usually  noticeable  on  walk- 
ing up  or  down  stairs,  or  after  over-exertion.  Shaffer,  who  first  called 
attention  to  the  disability,  thinks  that  it  may  be  a  predisposing  cause 
of  displacement  of  the  semi-lunar  cartilages.* 

Treatment. — In  this,  as  in  other  forms  of  insecurity  or  of  abnormal 
mobility  at  the  knee,  a  brace  that  allows  only  antero-posterior  motion, 
will,  as  a  rule,  relieve  the  symptoms.  If  the  ligament  is  of  such  a  length 
as  to  require  it,  it  may  be  shortened,  or  the  tubercle  of  the  tibia  may 
be  removed  and  implanted  at  a  lower  point,  as  suggested  by  Walsham.^ 

Other  Congenital  Deformities  at  the  Knee. 

Congenital  displacements  are  uncommon.  As  a  rule  they  are  incom- 
plete and  are  caused  by  laxity  of  the  ligaments  and  by  defective  for- 
mation of  the  bones  or  other  parts.^ 

Snapping  Knee. 

A  very  slight  form  of  partial  recurrent  displacement,  is  the  snapping 
or  clicking  knee  not  uncommon  in  early  infancy,  in  which  the  tibia  on 
sudden  extension  of  the  limb  springs  forward,  or  rotates  outward,  on 
the  femur,  with  an  audible  snapping  sound.  This  movement  appears 
to  be  the  result  of  voluntary  muscular  contraction  combined  with  laxity 
of  ligaments.  In  some  instances  the  subluxation  appears  to  cause  pain 
or  discomfort.  The  ability  to  displace  the  tibia  on  the  femur  by  mus- 
cular action,  is  sometimes  found  in  older  subjects. 

'  Lancet,  1891,  Vol.  I.,  p.  988. 

2  Archiv  di  Ortoped.,  1894,  p.  209. 

3  Trans.  Am.  Orth.  Ass'n,  Vol.  VIII.,  p.  228. 
Mbid.,  Vol.  XL 

5  Med.  Week,  February  17,  1893. 

^Drehmann,  Die  Cong.  Lux.  des  Kniegelenks.  Zeits.  f  iir  Orth.  Chir.,  Bd.  7,  H.  4, 
1900. 


•332     NON-TUBERCULOUS  AFFECTIONS  OF  THE  KNEE  JOINT. 

Treatment. — The  treatment  of  congenital  dislocations  or  subluxa- 
tions of  the  knee  consists  in  reposition,  support  and  massage  of  the 
■weak  part.  The  snapping  knee  may  be  supported  by  a  flannel  band- 
age, or  in  the  more  marked  type  of  laxity  of  ligaments,  it  may  be  fixed 
-for  a  time  in  a  brace.      Complete  recovery  is  the  rule. 

Congenital  Contraction  at  the  Knee. 

Slight  limitation  of  the  range  of  extension  of  one  or  both  knees  is 
not  infrequent.  As  a  rule  it  is  easily  overcome  by  massage  and  man- 
ipulation. In  the  more  extreme  cases  there  may  be  an  actual  de- 
formity' of  the  femur,  its  lower  extremity  presenting  a  forward  convex- 
ity, as  in  a  case  reported  by  Phocas.^ 

General  Contractions. 

Congenital  contraction  at  the  knees  of  a  more  marked  and  resistant 
form  may  be  combined  with  flexion  contraction  at  the  hip,  or  it  may 
be  one  of  a  series  of  contractions  at  other  joints.  In  the  latter  instance, 
other  congenital  deformities  or  evidences  of  defective  development  are 
usually  present.  For  example,  certain  joints  may  be  fixed  in  flexion 
or  fixed  in  extension.  In  some  instances  the  contraction  or  the  partial 
anchylosis  appears  to  be  due  simply  to  long-continued  fixation  in  utero, 
and  non-development  of  the  muscles.  In  others,  it  appears  to  be  a 
complication  of  so-called  foetal  rhachitis. 

Treatment.- — The  treatment  consists  in  regular  massage  and  manip- 
ulation, with  the  aim  of  increasing  the  range  of  motion.  Deformity,  if 
present,  may  be  rectified  in  the  usual  manner. 

Prognosis. — The  prognosis  depends  upon  the  cause  of  the  contrac- 
tion or  fixation.  In  most  instances,  under  careful  and  continued  treat- 
ment, the  range  of  motion  may  be  in  great  degree  restored. 

Acquired  Genu  Recurvatum. 

S3monym. — Back  Knee. 

Genu  recurvatum,  as  the  name  implies,  is  a  deformity  in  which  the 
knee  is  habitually  over-extended.  The  congenital  form  has  been  de- 
.scribed.     (See  page  328.) 

Etiology. — Acquired  genu  recurvatum  may  be  a  simple  local  de- 
formity, or  it  may  be  secondary  to  weakness  or  distortion  of  other 
parts.  Local  or  primary  genu  recurvatum  may  be  an  effect  of  rhachi- 
tis, or  of  disease  or  injury  of  the  femur  or  tibia.  In  this  form  the 
femur  may  be  curved  sharply  forward  above  the  joint,  or  the  upper 
extremity  of  the  tibia  may  be  bent  backward  at  the  epiphyseal  junction, 
and  flexion  may  be  limited  by  the  obliquity  of  the  articulating  surfaces. 

More  often  the  deformity  is  secondary.     It  may  be,  for  example,  an 

effect  of  equinus,  either  congenital  or  acquired,  in  which  the   knee  is 

strained  by  the  effort  of  the  patient  to  place  the  heel  upon  the  ground. 

It  may  be  caused  l)y  the  use  of  a  traction  brace  in  tlie  treatment  of  hip 

'  Revue  d'Oilliopedie,  January,  1899. 


ACQUIRED   GENU  RECURVATUM.  333: 

disease,  when  the  knee  joint  is  not  properly  supported.  It  is  one  of  the 
comparatively  infrequent  complications  of  disease  at  the  knee  joint,  in 
which  the  leg  has  been  supported  by  the  brace  in  an  extended  or  over- 
extended position.  In  rare  instances  it  is  the  direct  result  of  trauma- 
tism, when  the  leg  has  been  suddenly  forced  into  an  over-extended 
position,  and  the  posterior  ligaments,  and  possibly  the  crucial  ligaments 
also,  have  been  ruptured  or  weakened.  It  is  most  often,  however,  an 
accompaniment  of  paralysis  of  the  posterior  thigh  group,  or  of  the 
gastrocnemius  muscle,  or  both. 

In  the  majority  of  cases  genu  recurvatum  is  combined  with  a  vary- 
ing degree  of  knock  knee.  In  many  instances  there  is  an  abnormal 
mobility  at  the  joint  that  allows  a  certain  amount  of  posterior  displace- 
ment of  the  tibia,  and  in  extreme  cases,  there  may  be  well-marked 
subluxation. 

Symptoms. — The  symptoms,  aside  from  the  deformity,  are  weak- 
ness and  insecurity  caused  by  the  hyper-extension  when  weight  is 
borne.  If  the  deformity  is  extreme,  the  strain  upon  the  Aveakened 
parts  usually  causes  discomfort.  Flexion  is  rendered  difficult  because 
of  the  abnormal  relation  of  the  joint  surfaces  and  of  the  accommodative 
changes  in  the  ligaments  and  muscles,  so  that  in  extreme  cases  the  pa- 
tient swings  the  leg  along  in  the  extended  or  over-extended  position. 

Treatment. — If  the  recurvatum  is  caused  by  deformity  of  the  bones^ 
the  normal  relations  may  be  restored  by  osteotomy  of  the  tibia  or  fe- 
mur, as  may  be  indicated.  Deformity  secondary  to  distortions  else- 
where, may  be  treated  by  remedying  the  primary  cause. 

Traumatic  genu  recurvatum  may  be  treated  by  fixation  in  the  flexed 
position  until  the  repair  is  complete,  afterwards  by  massage  and  sup- 
port, if  necessary.  The  ordinary  form  of  over-extended  knee,  com- 
bined with  lateral  mobility,  must  be  supported  by  a  brace  which  per- 
mits only  antero-posterior  motion  to  the  normal  limit  or  slightly  less. 
Whenever  possible,  massage  and  exercises  should  be  employed. 


CHAPTER    XI. 
DISEASES  AND   INJUKIES  OF  THE  ANKLE  JOINT. 

Tuberculous  Disease  of  the  Ankle  Joint. 

Disease  of  the  ankle  is  the  third  in  the  order  of  importance,  although 
it  is  far  less  common  than  is  disease  at  the  knee. 

In  five  consecutive  years,  1,788  cases  of  tuberculous  disease  of  the 
joints  of  the  lower  extremity  were  treated  at  the  out-door  department 
of  the  Hospital  for  Euptured  and  Crippled.  In  54.1  per  cent,  of 
these  the  hip  joint  was  affected,  in  36.2  per  cent,  the  knee  joint,  and 
in  but  9.7  per  cent,  the  ankle  joint. 

Pathology. — The  pathology  of  tuberculous  disease  at  the  ankle  dif- 
fers in  no  essential  particular  from  that  of  disease  of  the  hip  and  knee. 


Tuberculous  disease  of  the  ankle  and  tarsus.    A,  disease  of  the  ankle  and  sub-astragaloid  joints  ;  B, 
cavity  in  the  os  calcis  containing  sequestrum. 

It  does  not  therefore  call  for  special  consideration.  It  is  of  interest 
to  note  however,  that  abscess  is  a  more  common  complication  at  this, 
than  at  the  other  joints. 

In  30  final  results  of  disease  at  the  ankle  reported  by  Gibney,^  ab- 
scess was  present  in  25,  83  per  cent.  In  78  final  results  reported  by 
Prendlsburger  ^  abscess  was  present  in  68,  87  per  cent.,  as  contrasted 
with  a  percentage  of  69  and  51  at  the  knee  and  hip  respectively.  This 
greater  liability  to  abscess  is  very  possibly  apparent  rather  than  actual, 
since  the  ankle  joint  is  so  superficial  that  fluctuation  may  be  detected 
lAm.  Jour.  Obstetrics,  April,  1880.  ^Lqc.  cit. 


ETIOLOGY. 


335 


here  that  would  be  overlooked  at  the  hip.  And  because  the  tissues 
about  the  joint  readily  allow  spontaneous  opening  at  an  early  stage, 
before  sufficient  time  has  elapsed  to  permit  of  spontaneous  absorption, 
that  is  so  common  in  disease  of  the  spine  and  hip. 

Situation  of  Disease. — Otto  Hahn  ^  has  recently  investigated  the 
■cases  of  tuberculous  disease  of  the  ankle  and  foot  treated  at  Tiibingen 
'during  the  past  fifteen  years.  These  cases  were  704  in  number  in 
•685  patients,  in  19  both  feet  having  been  involved. 

In  309  of  the  cases  the  disease  was  of  the  ankle  joint.  Of  these 
51  per  cent,  were  osteal  in  origin.  The  primary  focus  was  in  the 
iinternal  malleolus  in  11,  the  external  in  7,  in  both  in  5.  It  was  in 
the  astragalus  in  116  cases. 

In  16  instances  the  disease  of  the  ankle  was  secondary  to  primary 
'infection  of  the  os  calcis,  and  in  5  cases  both  the  astragalus  and  the  os 
•calcis  were  diseased. 

Etiology. — The  etiology  of  tuberculous  joint  disease  does  not  re- 
quire further  comment.  It  may  be  noted,  however,  that  tuberculous 
disease  at  the  ankle  is  relatively  more  common  in  later  childhood  and 
.adult  life  than  is  the  same  affection  at  the  knee  and  hip. 

Of  1,000  cases  of  disease  of  the  hip  joint,  12  per  cent,  were  in 
jpatients  more  than  1 0  years  of  age. 

Of  1,000  cases  of  disease  of  the  knee  joint,  25  per  cent,  were  in 
'^patients  more  than  10  years  of  age. 

Of  339  cases  of  disease  of  the  ankle  joint,  30  per  cent,  were  in  pa- 
itients  more  than  10  years  of  age.^ 


.Age  at  Incipiency  of  Ankle- Joint  Disease  in  339  Consecutive  Cases 
Treated  at  the  Hospital  for  Ruptured  and  Crippled. 


1  year  or  less 5     23  years  old. 

2  years  old 42 

3 
4 
5 
6 
7 


9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 


42 
43 

24  " 

25  " 

44 

26   " 

34 

27   " 

24 

28   " 

19 

29   " 

8 

30   " 

9 

31   " 

9 

32   " 

11 

33   " 

8 

34   " 

4 

35   " 

4 

36   " 

4 

37   " 

6 

40   " 

2 

43   " 

4 

44   " 

3 

45   " 

3 

46   " 

4 

48   " 

5 

50   " 

'Beitrage  zur  Klin.  Chir.,  Bd.  26,  H.  2,  1900. 

^  Statistics  from  Hospital  for  Ruptured  and  Crippled. 


...  2 

...  3 

...  3 

...  4 

...  4 

...  2 

2 

..  0 

...  1 

...  2 

..  1 

...  0 

,..  2 

,..  2 

..  4 

..  1 

..  1 

..  4 

2 

..  1 

..  1 
339 


336 


DISEASES  AND  INJURIES  OF  THE  ANKLE  JOINT. 


Of  the  339  patients  177  were  males  (52.2  per  cent.) ;  162  were  fe- 
males (47.8  per  cent.), 
cases  ;  of  the  left  in  166. 


The  disease  was  of  the  right  ankle  in  173 


Age  of  the  Patients  Treated  for  Ankle-Joint  and  Tarsal  Disease 
AT  Tubingen.     (Hahn.) 

Males.  Females.  Total. 

ItolOyeais 45  28  73 

11   "  20     "     149  91  240 

21  "  30     "     89  34  123 

31  "  40     "     32  28  60 

41   "  50     "     37  27  64 

51   "  60     ''     35  26  61 

61   "  70     "     18  11  29 

71   "  80     "     6  17 

81               "     1  _0  1 

412  246  658 

Of  658  patients  412  were  males  (62  per  cent.)  ;  246  were  females 
(38  per  cent.).     In  27  the  sex  was  not  stated. 

Symptoms. — The  symptoms  are  usually  subacute  in  character,  and 
are  often  mistaken  for  sprain  or  rheumatism.     In  some  instances  they 

FiC4.  234. 


Tuberculous  disease  (if  tlie  ankle. 


appear  to  follow  an  injury,  but  in  the  majority  of  cases  in  childhood  no 
cause  can  be  assigned.  The  ankle  becomes  sensitive  to  sudden  move- 
ments, the  patient  limps,  discomfort  after  over-use  and  pain  at  night 


BIAGNOSTS. 


337 


become  noticeable.  The  limp  differs  in  character  from  that  caused  by 
hip  or  knee  disease.  The  patient  walks  with  the  foot  rotated  outward, 
bearing  the  weight  upon  the  heel  and  upon  the  inner  border,  all  active 
leverage  being  avoided. 

Deformity. — The  primary  deformity  of  ankle-joint  disease,  in  the 
subacute  cases,  is  valgus,  induced  apparently  by  the  continued  use  of 
the  limb  in  the  passive  attitude.  In  more  advanced  cases  it  becomes 
equino-valgus  and  when  the  limb  is  no  longer  capable  of  supporting 
weight,  but  is  held  pendant,  the  equinus  deformity  predominates,  due 
partly  to  the  force  of  gravity  and  partly  to  the  muscular  spasm. 

As  has  been  stated,  in  the  early  stage  the  symptoms  are  those  of  a 

Fig.  235. 


Tuberculous  disease  of  the  sub-astragaloid  joint. 


persistent,  somewhat  painful  disability  at  the  ankle,  causing  stiffness, 
limp  and  at  times  pain ;  later  swelling  and  deformity  appear. 

Physical  Examination. — The  joint  is  usually  somewhat  enlarged. 
In  some  instances  the  swelling  is  uniform,  in  others  it  is  localized  in 
front  or  behind  one  of  the  malleoli.  This  swelling  is  not,  as  a  rule, 
like  that  of  simple  effusion  into  the  joint,  but  the  tissues  have  the  pe- 
culiar elastic  characteristic  of  thickening  and  infiltration.  There  is 
usually  a  perceptible  increase  in  the  local  temperature,  and  pressure  di- 
rectly upon  the  malleoli  causes  discomfort.  The  voluntary  movements 
of  the  joint  are  restricted  and  passive  movements  show  the  characteris- 
tic reflex  muscular  spasm,  limiting  both  dorsal  and  plantar  flexion. 
22 


Fig.  236. 


The  epiphyses  of  the  lower  extremities  at  the  age  of  s  x  years,  showing  the  eflFect  of  operative  re- 
moval of  bone  at  the  ankle  joint  for  tuberculous  disease  at  the  age  of  3  years,  in  causing  subsequent  de- 
formity of  the  foot  and  shortening  of  the  limb.  (oSS) 


TREATMENT.  339 

SuB-ASTEAGALOiD  DISEASE. — If  the  astragalus  is  primarily  dis- 
eased, -tMe  symptoms  are  usually  first  apparent  in  the  ankle  joint,  but 
in  certain  cases  the  joint  between  the  astragalus  and  the  os  calcis  is 
first  involved,  although  this  is  more  often  the  eiFect  of  primary  disease 
of  the  OS  calcis.  Disease  at  the  sub-astragaloid  joint  is  usually  classed 
as  ankle-joint  disease,  although  the  swelling  is  most  marked  at  a  point 
somewhat  below  the  malleoli.  (Fig-  235.)  Forced  lateral  motion  of 
the  OS  calcis  causes  discomfort,  and  the  range  of  adduction  and  abduc- 
tion of  the  foot  is  restricted,  while  dorsal  and  plantar  flexion  may  re- 
main completely  free. 

Diagnosis. — The  principles  of  differential  diagnosis  of  tuberculous 
disease  from  other  aiFections  have  been  considered  in  detail  in  the  de- 
scription of  disease  of  the  spine  and  of  the  larger  joints. 

In  childhood,  a  chronic,  painful  disease  confined  to  a  single  joint  in 
which  motion  is  limited  by  muscular  spasm,  and  in  which  there  is  a 
tendency  to  deformity,  is  almost  certainly  tuberculous  in  character. 

In  adult  life  also  the  same  principle  applies,  and  distinguishes  tu- 
berculous disease  from  rheumatism,  rheumatoid  arthritis  or  other  gen- 
eral affections.  Forms  of  infectious  arthritis  may  be  differentiated  by 
the  history.  Sprains  or  other  injury  may  be  distinguished  by  the  his- 
tory of  the  onset  and  by  the  absence  of  local  signs  of  serious  disease. 
In  rigid  flat  foot  the  symptoms  are  localized  at  the  medio-tarsal  joint. 
It  should  be  borne  in  mind,  also,  that  the  pain  from  a  weak  or  injured 
foot  is  experienced  as  a  rule  only  when  it  is  in  use,  whereas  in  tuber- 
culous disease  of  the  bone,  pain  is  common  when  the  part  is  not  in  use, 
and  it  may  be  particularly  troublesome  at  night. 

Treatment. — In  disease  of  this  as  of  other  joints  functional  rest  is 
indicated.  This  necessitates  fixation  and  stilting  of  the  limb,  efficient 
traction  being  manifestly  impossible.  The  foot  should  be  fixed  in  a 
light  plaster  bandage,  extending  from  the  extremities  of  the  toes  to  the 
calf,  at  a  right  angle  with  the  leg  and  in  an  attitude  of  slight  supina- 
tion, in  order  to  guard  against  the  tendency  toward  valgus.  This  de- 
formity is  very  common  after  the  cure  of  the  disease  and  it  often  sub- 
jects the  patient  to  the  additional  discomfort  of  progressive  flat  foot. 

R'-DUCTiON  OF  Deformity. — If  the  foot  has  become  distorted  be- 
fore the  patient  is  brought  for  treatment,  the  plaster  bandage  may  be 
applied  in  the  attitude  of  deformity,  and  at  the  subsequent  applications 
of  the  dressing,  when  the  muscular  spasm  is  lessened,  gentle  manipu- 
lation will  gradually  overcome  the  malposition.  Although  in  resistant 
cases  immediate  reduction  of  the  deformity  under  anaesthesia  may  be 
required.  Throughout  the  entire  course  of  treatment  the  greatest  at- 
tention must  be  paid  to  the  attitude.  Deformity  is  easily  prevented, 
but  it  is  often  very  difficult  to  correct,  especially  during  the  later  stages 
of  the  disease,  when  the  tissues  are  infiltrated  and  sensitive,  and  when 
discharging  sinuses  are  present. 

Other  retentive  appliances  may  be  employed,  but  they  are  inferior 
to  a  properly  applied  bandage  which  holds  its  place  by  accuracy  of  ad- 
justment, which  most  effectively  prevents  motion,  and  which  exercises 


340  DISEASES  AND  INJURIES  OF  THE  ANKLE  JOINT. 

a  certain  degree  of  compression  upon,  and  general  support  of,  the  swol- 
len joint.  The  bandage  is  renewed  at  intervals  of  a  month,  or  longer 
if  it  is  properly  protected  by  a  light  shoe  or  slipper. 

The  most  satisfactory  brace  to  serve  as  a  stilt  in  connection  with  the 
local  support  is  the  Thomas  brace,  which  has  been  described  in  the 
section  on  disease  of  the  knee  joint.     (Fig.  229.) 

A¥hen  patients  are  treated  efficiently  the  discomfort  or  inconvenience 
attending  the  disease  is  slight.  As  a  rule,  the  swelling  of  the  joint 
becomes  more  localized  and  finally  an  abscess  appears  beneath  the  skin. 
It  is  then  advisable  to  remove  the  fluid  and  other  contents,  by  means 
of  a  simple  incision.  In  most  instances  a  sinus  persists  for  a  time. 
If  the  discharge  is  slight,  the  part  may  be  dressed  with  ichthyol, 
balsam  of  Peru  or  other  application,  and  the  whole  inclosed  again  in 
the  plaster  bandage ;  or,  if  it  be  more  profuse,  an  opening  may  be 
made  and  the  dressing  applied  outside  the  plaster  bandage. 

Operative  Treatment. — Early  operation,  especially  gouging  opera- 
tions, should  be  avoided.  An  effective  operation  of  this  character  often 
iuvolves  the  sacrifice  of  bone  that  would  be  spared  in  the  natural  cure, 
thus  it  entails  an  irregularity  in  the  growth,  and  causes  deformity  in 
after  life,  which  may  be  irremediable.     (Fig.  236.) 

Similar  operations  in  the  treatment  of  fistulse,  or  abscess,  while  the 
tissues  are  thickened  and  oedematous,  and  while  the  disease  within  the 
joint  is  active,  should  be  postponed  until  the  process  of  repair  is  more 
advanced.  During  the  stage  of  convalescence,  however,  cure  may  be 
hastened  by  the  removal  of  persistent  foci  of  disease,  or  sequestra  in 
the  bone,  or  tuberculous  tracts  in  the  overlying  soft  parts. 

In  the  adult  or  adolescent,  and  in  exceptional  cases  in  childhood, 
operative  removal  of  the  disease  may  be  indicated,  and  if  it  is  confined 
to  the  ankle  joint,  the  removal  of  the  astragalus,  which  is  usually  the 
primary  seat  of  infection,  is  the  operation  of  choice. 

The  operation  is  performed  under  the  Esmarch  bandage ;  a  curved 
lateral  incision  is  made  passing  beneath  the  external  malleolus  from 
the  neighborhood  of  the  tendo-Achillis  to  the  anterior  aspect  of  the 
joint.  The  peroneii  tendons  and  the  lateral  and  capsular  ligaments  are 
divided,  after  which  the  foot  may  be  displaced  inward,  exposing  the 
joint,  the  ligament  between  the  astragalus  and  the  os  calcis  having 
been  separated,  the  bone  may  be  removed  with  a  little  manipulation  ; 
after  which  all  the  diseased  tissue  in  the  soft  parts  and  in  the  bone 
must  be  removed  thoroughly.  If  the  disease  has  not  extended  to  the 
tarsus,  and  if  it  seems  to  have  been  completely  removed,  the  wound 
may  be  closed  after  the  peroneii  tendons  are  sutured,  but  in  most  cases 
it  should  be  packed,  for  a  time,  with  gauze.  The  after-treatment  is 
conducted  as  if  the  operation  had  not  been  performed ;  support  and 
fixation  being  continued  until  it  is  evident  that  the  disease  is  cured. 

Removal  of  the  astragalus  does  not  interfere  to  a  marked  extent 
with  the  function  of  the  foot,  nor  does  it  cause  noticeable  deformity. 
As  a  primary  operation,  permitting  inspection  and  the  opportunity  for 
thorough  removal   of  all  disease  in  the  neighboring  parts,  it  should 


TUBERCULOUS  DISEASE  OF  THE  TARSUS.  341 

always  be  performed  in  preference  to  extensive  gouging,  which  is,  as  a 
rule,  of  little  avail. 

Prognosis. — Disease  at  the  ankle  is  not  only  less  common  but  it  is 
less  dangerous  than  that  of  the  larger  joints,  because  it  is  remote  from 
important  structures  and  because  there  is  less  opportunity  for  the 
burrowing  of  infected  abscesses.  The  duration  of  the  disease  here,  is, 
as  a  rule,  shorter  than  at  the  knee  or  hip,  and  the  final  results  in  child- 
hood, are  almost  always  excellent.  Often  free  motion  is  retained,  and 
even  if  the  astragalus  be  fixed  by  disease,  the  mobility  in  the  other 
joints  of  the  foot  is  sufficient  to  compensate  very  effectively  for  the 
anchylosis.  Shortening  of  the  limb  is  of  comparatively  little  conse- 
quence. It  is  not  often  more  than  an  inch,  and  it  may  be  absent. 
The  growth  of  the  foot  is  retarded  partly  from  disease,  and  partly 
because  of  the  destructive  effect  of  the  disease  upon  the  tarsal  bones. 

In  the  30  cases  reported  by  Gibney,  treated  expectantly,  in  which 
the  mechanical  treatment  was  far  from  effective,  (3  patients  recovered 
with  normal  motion  ;  11  with  practically  normal  function.  In  7  there 
was  good  motion.  In  6  there  was  anchylosis,  and  in  3  persistent 
valgus.  In  all,  the  limb  was  efficient.  In  20  instances  there  was  no 
limp,  and  in  but  one  case  was  it  marked.  In  no  instance  was  a 
crutch,  cane  or  other  support  used.  The  average  duration  of  the  dis- 
ease was  3  years  and  3  months,  a  minimum  of  1  year,  a  maximum  of 
6  years.  There  were  2  deaths,  of  which  but  1  was  dependent  upon 
the  disease,  septicaemia  being  the  cause  assigned,  though  it  is  stated  that 
practically  all  the  bones  of  the  tarsus  were  involved.  In  this  case 
amputation  was  evidently  indicated. 


Tuberculous  Disease  of  the  Tarsus. 

Tuberculous  disease  of  the  joints  of  the  foot,  not  involving  the 
ankle,  is  not  uncommon. 

In  386  of  the  704  cases  reported  by  Hahn,  the  disease  was  limited 
to  the  foot.  In  141  cases  the  medio-tarsal  joint  was  involved,  in  51 
of  these  the  disease  was  confined  to  this  joint ;  in  46  the  ankle  was 
involved ;  in  29  the  disease  extended  forward  to  the  tarso-metatarsal 
articulation,  and  in  16  the  three  joints  were  diseased.  In  78  cases 
the  tarso-metatarsal  joint  was  involved,  in  33  of  which  the  disease  did 
not  extend  beyond  this  articulation. 

Disease  of  Ixdividual  Bones. — In  these  cases  the  distribution 
was  as  follows : 

The  astragalus 170;  disease  confined  to  the  single  bone  in    8 

The  calcaneum 200;       "  "  "         "  "     "87 

The  cuboid 116;       "  '^  ''         "  "     "18 

Thescaphoid 82;       "  "  "         "  "     "     2 

The  cuneiform  bones..  86;       "  "  "         "  "     "     8. 

Metatarsal  bones 45  ;   in  one-half  of  these  the  disease  was  of 

the  1st  metatarsal,  either  alone  or  in  connection  with  the  adjoining 
cuneiform  bone  or  phalanx. 


342  BISEASES  AND  INJURIES  OF  THE  ANKLE  JOINT. 

In  a  total  of  1,231  cases,  including  these  and  others  reported  by 
Audry,^  Koenig,^  Mondan,"^  Miinch,*  Spengler,'*  Vallas,^  Czerny  '^  and 
Duniont,^  the  relative  frequency  of  the  disease  in  the  bones  of  the  foot 
and  ankle  appeared  to  be  as  follows  : 

Malleoli 96,     7.7percent.  Scaphoid 110,  8.9percent. 

Astragalus 291,23.6       "  Cuneiform  bones  109,  8.8       " 

Calcaneus 339,  25.9       "  Metatarsus 110,  8.9       " 

Cuboid 154,  12.5       "  Phalanges 22,  1.7       " 

Peimary  Disease  of  the  Asteagalo-scaphoid  Joint. — In  dis- 
ease at  this  point  the  swelling  is  localized  in  front  of  the  ankle  on  the 
inner  side  of  the  foot.  Adduction  is  restricted  and  the  foot  is  often 
fixed  in  an  attitude  of  persistent  abduction. 

Disease  of  other  bones  of  the  tarsus  is  indicated  by  the  local  swelling 
and  sensitiveness.  The  disease  sometimes  involves  the  shaft  of  a  meta- 
tarsal bone,  or  one  of  the  phalanges,  causing  expansion  and  destruction, 
"  spina  ventosa."     (See  page  356.) 

Treatment  of  Tarsal  Disease. — Disease  of  the  tarsus  shows  a 
marked  tendency  to  extend  from  one  bone  to  another  until  the  entire 
foot  is  involved.  Consequently  if  an  early  diagnosis  is  made  of  a  dis- 
tinctly localized  process,  prompt  removal  of  the  diseased  bone  is  indi- 
cated. But  in  most  instances  the  disease  is  too  extensive  to  permit  of 
its  radical  removal.  In  such  cases  operative  intervention  is  contra- 
indicated,  and  the  treatment  by  protection,  similar  to  that  employed  in 
disease  of  the  ankle,  is  indicated.  In  childhood  the  prognosis  is  very 
good  even  when  the  disease  is  extensive,  but  in  adult  life  amputation 
of  the  foot  may  be  advisable,  especially  if  there  be  co-existent  disease 
of  the  lungs. 

Sprain  of  the  Ankle. 

The  ankle  is,  from  its  position,  especially  liable  to  injury,  in  fact 
the  term  "  sprain  "  is  popularly  associated  with  this  joint. 

A  sprain  is  most  often  caused  by  an  unguarded  movement,  by  which 
the  foot  is  turned  suddenly  inward  or  outward,  with  sufficient  force  to 
rupture  some  of  the  fibers  of  the  muscles,  to  strain  tendons  and  tendon 
sheaths  and  even  to  rupture  ligaments.  If  the  foot  is  twisted  inward, 
the  injury  is  most  marked  on  the  outer  side  of  the  joint ;  if  outward, 
on  the  inner  side  of  the  ankle.  In  the  slighter  degrees  of  sprain,  the 
injury  may  be  confined  to  the  tissues  about  the  joint,  but  in  most  in- 
stances there  is  effusion  within  the  capsule,  even  hemorrhage  when  the 
injury  has  been  severe. 

Symptoms. — The  immediate  symptoms  of  sprain  are  pain,  often  in- 
tense, of  a  throbbing  character,  swelling,  heat  and  in  many  instances, 

1  Eevue  de  Chir.,  1891.  ^ Ibid.,  Bd.  44,  1897. 

^Schmidt's  Jahrb.,  Bd.  204,  1884.  « Deutsche  Chir.,  L.  66. 

3  Deutsche  Chir.,  L.  66.  '  Volk.  S.  klin.,  V.,  No.  76. 

*  Deutsche  Zeits.  f.  Chir.,  Bd.  11,  1879.  s  Deutsche  Zeits.  f.  Chir.,  Bd.  17,  1882. 


SPRAIN   OF  THE  ANKLE.  343 

discoloration  of  the  surrounding  parts,  even  extending  over  the  leg 
and  fobt. 

Treatment. — If  an  opportunity  for  immediate  treatment  is  offered, 
the  swelling  and  the  effusion  of  blood  may  be  restrained  by  the  appli- 
cation of  elastic  stockinette  bandages,  from  the  toes  to  the  knee.  As 
much  compression  is  exercised  as  the  comfort  of  the  patient  will  allow, 
and  the  bandage  should  be  made  sufficiently  thick  to  prevent  painful 
motion.  If  the  injury  has  been  severe  and  if  the  part  is  very  sensi- 
tive to  motion  or  jar,  the  joint  having  been  protected  with  cotton  may 
be  fixed  in  a  light  plaster  bandage.  This  may  be  cut  down  the  front 
to  allow  for  daily  massage  of  the  foot,  ankle  and  leg  which  is  of  great 
service  in  hastening  the  absorption  of  the  effusion. 

The  use  of  hot  air,  hot  and  cold  water  and  static  electricity,  and  the 
like,  are  of  service  also  in  relieving  the  discomfort  and  especially  in 
stimulating  the  circulation  of  the  blood,  upon  which  repair  depends. 

Fig.  237. 


Adhesive  plaster  strapping  applied  for  sprain  of  the  ankle. 

By  far  the  most  effective  treatment  during  the  stage  of  recovery  and 
as  an  immediate  application  for  sprains  of  slighter  degree,  is  the  ad- 
hesive plaster  strapping  which  has  been  popularized  by  Gibney.  The 
plaster  may  be  applied  in  a  variety  of  ways  ;  a  satisfactory  method  is 
as  follows. 

One  end  of  a  strip  of  adhesive  plaster  about  three  feet  long  and 
three  inches  wide,  is  applied  to  the  lateral  aspect  of  the  leg  just  below 
the  knee  joint ;  it  is  carried  down  the  side  of  the  leg  over  the  malleolus, 
beneath  the  heel  and  arch,  and  up  the  other  side  to  a  point  opposite 
the  beginning,  where  it  is  fixed  by  a  circular  band  about  the  calf.  If 
the  sprain  is  of  the  outer  side  of  the  ankle,  sufficient  tension  is  made 
upon  the  outer  half  of  the  plaster  to  hold  the  foot  slightly  abducted. 
If,  as  is  more  common,  the  sprain  is  of  the  inner  side,  the  inner  half  is 
drawn  firmly  beneath  the  arch,  carrying  the  foot  toward  inversion  so 
that  all  strain  may  be  removed  from  the  sensitive  part.     This  band  of 


344 


DISEASES  AND  INJURIES  OF  THE  ANKLE  JOINT. 


plaster  is  reinforced  by  one  or  more  so  that  tlie  lateral  aspect  of  the 
ankle  is  completely  covered.  And  in  addition  the  entire  ankle,  with 
the  exception  of  the  heel,  is  then  enclosed  with  narrow  overlapping 
strips,  which  cover  all  the  tissues,  well  beyond  the  sensitive  area.  The 
foot  and  leg  are  then  bandaged  to  assure  the  adhesion  of  the  plaster. 
When  the  joint  is  firmly  held  by  the  supporting  plaster,  the  patient 
can,  as  a  rule,  walk  with  comfort ;  and  he  is  encouraged  to  do  so,  for 
functional  use,  provided  it  does  not  cause  additional  injury,  is  the  most 
effective  stimulant  of  the  circulation  ;  thus  the  patient  applying,  as  it 
were,  an  automatic  massage,  cures  himself. 

As  the  swelling  subsides  the  plaster  strapping  wrinkles,  and  it  must 
be  renewed,  about  three  applications  being  required  as  a  rule,  the  last 
of  which  is  allowed  to  remain  until  all  of  the  symptoms  have  disap- 
peared. It  is  perhaps  needless  to  state  that  a  preliminary  shaving  of 
the  part  will  add  somewhat  to  the  comfort  of  the  patient.     Gibney  ad- 


FiG.  238. 


The  stockinette  baudage. 


vises  the  use  of  narrow,  overlapping  strips  and  does  not  cover  the  front 
of  the  ankle ;  the  manner  of  application  is,  however,  of  little  impor- 
tance provided  that  the  sensitive  part  is  efficiently  supported  and  com- 
pressed. 

Chronic  Spraix. — A  chronic  sprain  may  be  the  result  of  an  inef- 
ficiently treated  acute  injury,  in  which  an  improper  attitude  originally 
assumed  to  spare  the  sensitive  part,  finally  becomes  habitual.  In  other 
instances,  persistent  disability  may  be  the  result  of  fixation  of  the  joint 
for  too  long  a  time  in  splints.  Such  disuse  cau.ses  atrophy  of  the  muscles, 
while  the  effused  material  within  and  without  the  joint  remains  because 
of  the  imperfect  circulation.  The  same  disability  may  follow  simple 
disuse  of  the  injured  part.  It  is  more  often  observed  in  nervous  indi- 
viduals who  exaggerate  the  importance  of  the  injury  and  the  discomfort 
that  it  causes.  In  such  cases  the  limb  may  be  discolored  by  venous 
congestion,  the  foot  may  be  oedematous  and  the  movements  may  be 
limited  by  adhesions  or  by  muscular  adaptation  to  the  habitual  attitude. 


TENO-SYNO  VITI8. 


345 


Fig 


In  other  instances  the  original  injury  may  have  caused  a  slight  sub- 
luxatiori  of  the  astragalus,  sufficient  to  throw  the  foot  into  an  attitude  of 
abduction,  in  which  it  has  become  fixed  by  the  secondary  changes  in  the 
muscles  and  ligaments.  In  some  cases  of  this  class  the  original  sprain 
was  at  the  medio-tarsal  or  at  the  sub-astragaloid  joint,  and  its  effect 
has  been  a  traumatic  weak  foot.  Finally,  many  of  the  so-called 
sprains  of  the  ankle  are  simply  injuries  of  a  weak  foot  and  are  ex- 
amples of  the  rigid  or  inflamed  weak  or  flat  foot.     (See  the  Weak  Foot.) 

Treatment.  —  Treatment  must  be 
conducted  with  the  aim  of  restoring  the 
normal  range  of  motion  and  so  support- 
ing the  part  that  normal  functional  use 
may  be  permitted.  In  many  instances 
when  adhesions  have  formed,  and  when 
the  foot  is  persistently  held  in  an  ab- 
normal attitude,  forcible  manipulation 
under  anaesthesia  may  be  required  as  a 
preliminary  treatment  followed  by  fixa- 
tion for  a  time  in  a  plaster  bandage,  in 
the  attitude  directly  opposed  to  that 
which  had  been  habitual.  And  as  in 
this  class  of  cases  the  habitual  attitude 
is  usually  one  of  equi no- valgus,  the 
foot  should  be  fixed  for  a  time  in  a 
plaster  bandage  in  a  position  of  extreme 
varus,  and  upon  it  the  patient  is  en- 
couraged to  bear  his  weight  both  in 
standing  and  walking.  When  all  dis- 
comfort has  disappeared,  a  support, 
usually  a  light  leg  brace  to  prevent 
lateral  motion,  and  if  the  arch  is  de- 
pressed a  foot  plate  also,  should  be  worn 
for  a  time.  The  most  effective  curative 
agent  is  functional  use,  but  massage, 
hot  air,  passive  manipulation  and  exer- 
cises are  of  service  also. 

Injuries  of  this  class  are  very  amen- 
able to  treatment,  conducted  with  the 
aim  of  restoring  normal  function,  when 
proper  support  is  provided  during  the 
period  of  pain  and  weakness. 

Teno-Synovitis. 

The  sheaths  of  the  tendons  about 
the  ankle  joint,  if  involved  in  a  sprain 

rt    .1  11  '   j_       1    •  The  anterior  annular  ligament  of  the 

OI    the  ankle,  may  cause    persistent  in-     ankle  and  the  synovial  membranes  of  the 

ierference  with  function  ;  or  strain  of  fT^Elxux.^TF^^Vk^'rS 


346 


DISEASES  AXn  INJURIES   OF  THE  ANKLE  JOIXT. 


The  internal  annular  ligament  of  the  ankle  and  the  arti- 
ficially distended  synovial  membranes  of  the  tendons  which 
it  confines,     i  Testut.  i     (From  Gerrish's  Anatomy,  j 


a  tendon  and  of  its  sheatli  mav  cause  symptoms  of  disability  when  the 
joint  is  uninjured.     The  symptoms  of  acute  teno-synovitis  are  discom- 
fort on  motion  of  the  af- 
FiG.  240.  fected    tendon    and    this 

motion  may  be  accom- 
panied by  a  peculiar  creak- 
ing which  is  apparent  on 
palpation.  In  many  in- 
stances there  is  slight  local 
swelling:  and  sensitiveness 
to  pressure  about  the  af- 
fected part,  and  the  general 
movements  of  the  foot  that 
call  the  muscle  into  action 
are  painful. 

The  arrangement  of  the 
tendon  sheaths  should  be 
borne  in  mind.  At  the 
ankle  joint  all  the  tendons 
are  provided  with  sheaths ; 
on  the  front  of  the  foot  are 
three — the  sheath  of  the 
tibialis  anticus,  which  ex- 
tends from  a  point  about  two  inches  above  the  extremity  of  the  malleo- 
lus to  the  scaphoid  bone  (Fig.  239);  that  of  the  extensor  longus  poUicis, 
from  the  annular  ligament  to 
the  head  of  the  first  metatarsal, 
and  the  common  sheath  for  the 
extensor  communis  digitorum 
extending  from  a  point  about 
half  an  inch  above  the  malleoli 
to  about  one  inch  below  the 
annular  ligament.  Behind  the 
internal  malleolus  are  the  com- 
mon sheaths  of  the  tibialis 
posticus  and  flexor  longus  digi- 
torum, beginning  about  an  inch 
above  the  extremity  of  the 
malleolus  and  extending  to  the 
astragalo  -  scaphoid  junction 
and  that  of  the  flexor  longus 
pollicis  of  about  the  same  ex- 
tent. (Fig.  240.)  Behind  the 
outer  malleolus  is  the  sheath  of 
the  two  peroneii,  beginning  one 
inch  above  the  malleolus,  divid- 
ing into  two  portions  for  the 
two  tendons  and  ending  just  behind  the  tuberosity  of  the  fifth  metatarsal 
bone.     (Fig.  241.) 


The  external  annular  ligament  of  the  ankle  and  the 
artificially  distended  synovial  membrane  of  the  ten- 
dons which  it  confines.  (Testut.)  (From  Gerrish's 
Anatomy.) 


OTHER  AFFECTIONS   OF   THE  ANKLE  JOINT.  347 

Treatment. — Simple  traumatic  teno-synovitis  should  be  treated  by 
rest  and  by  compression.  An  effective  treatment  is  strapping  by  ad- 
hesive plaster,  so  applied  as  to  prevent  the  movements  of  the  foot 
that  cause  discomfort.  In  more  painful  and  persistent  cases  the  use  of 
a  plaster  bandage  to  assure  absolute  rest  may  be  necessary.  Cautery 
applied  over  the  affected  part  is  of  service.  Chronic  teno-synovitis 
may  follow  injury  or  it  may  be  the  result  of  gonorrhoea  or  other  infec- 
tious disease.  In  chronic  cases  when  the  palliative  treatment  is  inef- 
fective, thorough  removal  of  the  affected  sheath  is  indicated. 

Tuberculous  Teno-synovitis. — A  persistent  and  increasing  swell- 
ing of  a  tendon  sheath  always  suggests  tuberculous  disease.  In  such 
instances  the  sac  is  thickened  and  often  contains  the  so-called  rice 
bodies.  Prompt  and  complete  removal  of  the  diseased  sheath  is  indi- 
cated and  by  this  means  a  permanent  cure  may  be  attained  in  most 
instances. 

Other  Affections  of  the  Ankle  Joint. 

The  ankle  joint  may  be  the  seat  of  an  infectious  arthritis ;  it  may 
be  involved  in  an  osteomyelitis  of  the  tibia.  It  may  be  one  of  the 
joints  affected  in  chronic  rheumatism  or  rheumatoid  arthritis,  and  oc- 
casionally Charcot's  disease  may  appear  in  this  situation.  The  princi- 
ples of  the  treatment  of  these  affections  have  been  indicated  elsewhere. 


CHAPTER    XII. 

DISEASES   AND   INJURIES   OF    THE    ARTICULATIONS 
OF  THE  UPPER  EXTREMITY. 

Tuberculous  Disease  of  the  Shoulder  Joint. 

Disease  of  the  shoulder  is  very  uncommon  in  childhood.  In  a 
total  of  453  cases  of  tuberculous  disease  treated  at  the  Vanderbilt 
Clinic  210  were  cases  of  Pott's  disease.  In  6  of  the  remaining  243 
cases,  the  disease  was  of  the  shoulder  joint  (2.5  per  cent.). 

In  1,883  consecutive  cases  of  joint  disease — Pott's  disease  being 
excluded — treated  in  the  Out-patient  Department  of  the  Hospital  for 
Ruptured  and  Crippled  during  the  past  five  years,  the  shoulder  joint  was 
involved  in  38  instances  (2  per  cent.).  In  1,900  cases  of  joint  disease 
treated  at  Billroth's  Clinic,  the  shoulder  was  involved  in  14,  or  less 
than  1  per  cent. 

Fig.  242. 


\ 

Section  of  the  shoulder  joint,  in  childhood.     (Schuchardt.  ) 

Pathology. — The  disease  usually  begins  in  the  head  of  the  humerus. 
In  32  observations  on  adults  recorded  by  Mondan  and  Andry,^  the 
primary  disease  was  of  the  head  of  the  humerus  in  23  cases,  of  the 
humerus  and  scapula  in  4,  of  the  scapula  alone  in  1  and  in  3  instances 
it  appeared  to  be  primarily  synovial. 

In  the  majority  of  cases  abscess  forms  and  comes  to  the  surface  near 
the  insertion  of  the  deltoid  muscles.  In  advanced  cases  the  tissues  of 
the  axilla  and  of  the  adjoining  thorax  may  be  infiltrated  and  perforated 
by  numerous  sinuses.     In  other  instances  the  disease  is  of  the  form 

'  Revue  de  Chir.,  1892. 


SYMPTOMS.  349 

called  caries  sicca,  in  which  there  is  no  swelling,  but  progressive  destruc- 
tion of  the  head  of  the  humerus  by  granulation  tissue.  This  form  is 
charalcterized  by  extreme  muscular  atrophy  and  by  practical  anchylosis. 

Statistics. 

Age  at  Incipiency  of  Disease  at  the   Shoulder  Joint  in   62   Con- 
secutive Cases   Treated  at  the   Hospital  for  Rup- 
tured AND  Crippled. 

1  year  or  less 1     13  years  old 3 

2  years  old 6 

3  "       "  

4  ii       u 

5  "       "  

6  "       "  

17  u  u 


9 
10 
11 
12 


Males  38,  females  24 


fi 

15 

18 
19 
20 
23 
26 
27 
34 
48 
56 

;  rig 

ht35, 

2 

1 

3 

3 

5 

3 

4 

1 

1 

3 

2 

4 

1 

fi 

1 

1 

1 

5 

1 

4 
24 

Total 

left  27. 

."62 

Townsend '  made  a  detailed  report  on  2 1  cases  treated  at  the  Hos- 
pital for  Ruptured  and  Crippled  during  the  years  1889  to  1893.  Ten 
of  these  were  less  than  ten  years  of  age,  7  were  between  ten  and  twenty, 
and  4  were  more  than  twenty.  The  youngest  patient  was  three  and 
a-half  and  the  age  of  the  oldest  was  thirty-five  years.  In  5  cases  the 
disease  was  secondary  to  disease  of  other  parts  ;  in  one  case  to  Pott's 
disease,  in  2  to  hip  disease  and  in  2  to  disease  of  the  knee  joint. 

Symptoms. — The  history  of  the  case  will  show  the  persistent  and 
progressive  character  of  the  disability,  but  the  symptoms,  characteristic 
of  tuberculous  disease,  are  far  less  marked  at  the  shoulder  than  at 
other  joints.  This  is  explained  by  the  fact  that  the  upper  extremity  is 
not  subjected  to  the  strain  of  weight-bearing  and  because  the  mobility 
of  the  scapula  upon  the  thorax  lessens  the  injury  caused  by  unguarded 
movements  of  the  arm.  This  double  joint  at  the  shoulder  masks  the 
interference  with  the  function  of  the  joint,  and  even  when  absolute 
anchylosis  is  present  the  patient  may  think  that  the  movements  are  but 
moderately  restricted.  Finally,  the  traumatism  caused  by  over-use  may 
be  lessened  by  the  voluntary  restraint  that  the  patient  may  exercise 
upon  motion  at  this  joint,  without  greatly  inconveniencing  himself. 

The  symptoms  of  the  disease  may  be  classified  as  pain,  sensitiveness, 
restriction  of  motion,  atrophy. 

The  pain  is  usually  of  a  dull  aching  character  with  occasional  neu- 
ralgic pain  referred  to  the  elbow  and  arm.  The  discomfort  is  increased 
by  movements  that  pass  beyond  the  limits  allowed  by  the  mobility  of 
the  scapula,  especially  on  attempting  to  rotate  the  humerus,  as  in 
clothing  oneself  or  brushing  the  hair.  The  joint  is  sensitive  to  pressure, 
thus  the  patient  finds  that  he  can  not  lie  on  the  aft'ected  side  at  night. 
1  Trans.  Am.  Orth.  Ass'n,  Vol.  VII. 


350     DISEASES  OF  ARTICULATIONS  OF  UPPER  EXTREMITY. 

On  physical  examination  the  limitation  of  motion  caused  by  muscular 
spasm  will  be  evident  when  the  scapula  is  fixed,  so  that  movement  of  the 
joint  can  be  tested.  Normally  the  range  between  adduction  and  abduc- 
tion is  about  90  degrees,  and  between  flexion  and  extension  it  is  some- 
what less  than  this. 

Pressure  upon  the  head  of  the  humerus  usually  causes  pain,  and  in 
many  instances  local  heat  and  swelling  are  present.  The  atrophy  of 
the  shoulder  muscles  is  often  extreme  and  that  of  the  other  muscles  of 
the  limb  is  well  marked. 

As  has  been  stated,  abscess  is  a  common  accompaniment  of  the  dis- 
ease, and  in  such  cases  the  tissues  about  the  joint  are  swollen  and  in- 
filtrated. In  other  instances  there  is  progressive  destruction  of  the 
head  of  the  humerus  without  abscess  formation  (Caries  sicca).  In 
cases  of  this  type  the  flattening  of  the  shoulder  may  be  so  extreme  as 
to  be  mistaken  for  sub-coracoid  dislocation. 

Treatment. — The  treatment  of  the  disease  here  as  elsewhere  is  rest. 
To  assure  absolute  functional  rest  the  wrist  should  be  attached  to  the 
neck  by  a  sling,  the  elbow  being  flexed  to  an  acute  angle ;  the  arm  is 
then  fixed  to  the  thorax  by  a  bandage  and  all  the  clothing,  including 
the  shirt,  is  placed  outside  the  affected  part.  Local  rest  and  compres- 
sion may  be  still  further  assured  by  strips  of  adhesive  plaster  applied 
over  the  shoulder  and  extending  to  the  back  and  chest ;  or  a  shoulder 
cap  of  leather  or  plaster  may  be  employed.  This  method  of  fixing  the 
arm  is  the  only  one  that  assures  continuous  rest,  as  a  change  of  the 
clothing  necessitates  movement  of  the  joint,  which  causes  discomfort 
and  retards  the  cure.  During  the  acute  phases  of  the  disease,  the  arm 
may  be  supported  in  the  attitude  of  extreme  abduction  by  means  of  a 
triangular  splint  or  pad.  This  position  is  often  that  of  greatest  com- 
fort to  the  patient.  Direct  traction  is  not  often  employed,  as  support 
of  the  pendant  limb  is  usually  preferred  by  the  patient. 

Operative  Treatment. — If  the  focus  of  disease  seems  to  be  localized, 
an  exploratory  operation  for  its  early  removal  may  be  indicated.  Ex- 
cision of  the  joint  in  the  adult  cases,  or  arthrectomy  in  younger  sub- 
jects, may  be  advisable  when  suppuration  is  persistent  or  when  for 
other  reasons  it  may  seem  best  to  attempt  to  remove  the  diseased  area. 

Prognosis. — The  duration  of  the  disease  appears  to  be  from  two  to 
five  years.  The  death  rate  is  higher  than  in  disease  of  the  joints  of  the 
lower  extremity,  because  a  larger  proportion  of  the  patients  are  adults 
and  in  this  class  tuberculosis  of  the  lungs  is  not  an  infrequent  compli- 
cation. 

It  is  impossible  to  speak  positively  of  the  results  of  the  conserva- 
tive treatment  of  disease  of  the  shoulder.  The  disease  is  uncommon 
and  protection  is  almost  never  applied  in  the  early  stage,  nor  efficiently 
or  persistently  employed  to  the  end.  The  ordinary  result  is  therefore 
anchylosis,  usually  of  the  fibrous  rather  than  of  the  bony  variety. 

If  the  disease  appears  in  early  life  the  growth  of  the  limb  may  be 
seriously  interfered  with  ;  an  inch  or  more  of  shortening  from  this  cause 
is  not  uncommon. 


TUBERCULOUS  DISEASE  OF  THE  ELBOW  JOINT.  351 

Tuberculous  Disease  of  the  Elbow  Joint. 

Tuberculous  disease  of  the  elbow  joint  is  the  fourth  in  order  of  fre- 
quency, preceding  the  shoulder  and  the  wrist.  Of  1,883  consecutive 
cases  of  joint  disease  treated  at  the  Hospital  for  Ruptured  and  Crippled, 
56  were  of  the  elbow. 

Pathology. — The  primary  disease  is  in  most  instances  osteal,  as  in 
92.8  percent,  of  the  cases  investigated  by  Scheimpflug,  44  in  number.^ 
The  original  focus  of  infection  is  somewhat  more  often  of  the  ulna  than 
of  the  humerus.  Of  the  ulna  the  olecranon  process,  and  of  the  humerus 
the  external  condyle,  appear  to  be  the  points  of  election.  Disease  of  the 
head  of  the  radius  is  comparatively  infrequent.  In  11 9  cases  reported 
by  Oilier,  the  olecranon  was  involved  in  73,  the  humerus  in  33  and 
the  radius  in  12  instances.^  And  in  the  cases  investigated  by  Kummer,^ 
and  Middledorpt,^  the  ulna  was  more  often  the  seat  of  the  primary 
disease  than  was  the  humerus,  but  in  81  cases  treated  in  Koenig's 
clinic  the  primary  disease  was  of  the  humerus  in  43,  of  the  olecranon 
in  36  and  of  the  radius  in  2  instances.^ 

Statistics. 

Age  at  Incipiency  of  Disease  at  the  Elbow  Joint  in  59   Consecu- 
tive Cases  Treated  at  the  Hospital  for  Euptured 
AND  Crippled. 

1  year  or  less 2     11  years  old 1 

2  years  old 5 

3  "       "  

4  u        u 

5  "       "  

6  "       "  

"7  H  U 


9 
10 


Males  28,  females  31 


5     13      " 

( 

3 

8     14      " 

'  2 

5     15      " 

5     17      " 

4     19      " 
8     21      " 

1     23      " 

2     25      " 

'   2 

5     29      " 

'   1 

s  31  ;  right  27 

Total 

,  left  32. 

59 

Symptoms. — The  symptoms  are  those  of  a  chronic,  persistent,  de- 
structive disease.  Pain,  local  sensitiveness  and  swelling,  stiffness,  de- 
formity, atrophy. 

The  pain  is  usually  localized  at  the  elbow.  It  is  increased  by  sud- 
den movements,  and  as  the  bones  are  so  superficial  there  is  usually 
local  sensitiveness  to  pressure,  most  marked  over  the  seat  of  the  dis- 
ease. In  the  early  stage  the  swelling  is  slight  and  it  is  of  the  peculiar 
elastic  character  due  to  thickening  of  the  tissue,  rather  than  to  effusion 
within  the  capsule,  but  as  the  disease  progresses  the  joint  assumes  the 
peculiar  spindle  shape  characteristic  of  white  swelling.  The  degree 
of  elevation  of  the  local  temperature  depends  upon  the  activity  of  the 

>  Festschrift  fiir  Billroth,  1892. 

^Karewski,  Chir.  Krank.  des  Kindersalters,  p.  268. 

3 Deutsche  Zeits.  f.  Chir.,  Bd.  27. 

*  Archiv  f.  Klin.  Chir.,  Bd.  33. 

^Koenig,  Lehrbuch  Spec.  Chir.,  Berlin,  1900. 


352     DISEASES  OF  ARTICULATIONS  OF   UPPER  EXTREMITY. 


disease.  The  most  important  physical  sign  is  the  restriction  of  motion 
due  to  the  characteristic  muscular  spasm  which  becomes  evident  when 
the  limit  of  painless  motion  is  passed.  The  limitation  of  extension 
and  flexion  gradually  increases  and  finally  the  limb  becomes  fixed  in 
an  attitude  midway  between  flexion  and  extension,  with  the  forearm 
in  an  attitude  midway  between  pronation  and  supination.     This  is  the 

characteristic    deformity   of  the 
Fig.  243.  disease. 

Atrophy  of  the  muscles  of  the 
arm  and  forearm  is  present,  cor- 
responding to  the  intensity  and 
duration  of  the  disease  and  to  the 
functional  disability  of  the  joint. 
Treatment.  —  The  treatment 
here,  as  elsewhere,  consists  essen- 
tially in  placing  the  joint  at  rest 
in  the  attitude  at  which  anchylo- 
sis or  limitation  of  motion  will 
least  inconvenience  the  patient, 
and  at  the  elbow  joint,  this  is 
])ractically  at  right-angular  flex- 
ion.    (Fig.  244.) 

In    the    treatment    of   young 
children  the  wrist  may. be    at- 
tached   closely  to  the   neck    by 
means  of  a  sling,  with  the  elbow 
at  an  acute  angle  (the  Thomas 
method)  within  the  clothing.     Or 
a  light  plaster  bandage  may  be 
used    to    fix  the  joint,  together 
with  the  sling.     This  enables  the 
patient  to  dress  himself  without 
moving  the  part  and  it  protects 
the    joint    from    injury.     Other 
forms  of  splints  may  be  employed,  but  the  plaster  bandage  answers 
every  purpose.     It  should,  of  course,  extend  from   the  axilla  to  the 
hand,  and  in  sensitive  cases  it  may  include  the  hand  also. 

Reduction  of  Deformity. — In  many  instances  the  arm  is  fixed  in 
the  semi-extended  attitude  when  the  patient  is  brought  for  treatment. 
In  this  class  of  cases  a  simple  and  effective  means  of  reducing  deform- 
ity is  that  suggested  by  Thomas.  When  it  is  impossible  to  bring  the 
wrist  to  the  neck,  one  bends  the  neck  toward  the  wrist  and  attaches 
the  two  by  a  bandage  that  the  patient  is  unable  to  remove.  From  this 
uncomfortable  attitude  the  patient  can  free  himself  only  by  drawing  the 
arm  toward  the  neck  and  thus  reducing  the  deformity.  At  the  next 
visit  the  same  procedure  is  repeated,  until  finally  the  elbow  is  flexed  to 
the  required  degree.  A  permanent  sling  may  be  constructed  of  a  leather 
wrist  band  and  a  tube  of  leather  to  pass  about  the  neck,  through  which 


Tuberculous  disease  of  the  elbow  joint. 


OPERATIVE  TREATMENT. 


353 


the  bandage  may  be  drawn  ;  thus  the  pressure  on  the  wrist  and  neck 
may  be.; lessened.  In  the  very  resistant  cases  reduction  of  deformity 
under  anaesthesia  may  be  required,  but  this  is  not  often  necessary. 

Prognosis. — If  the  case  is  treated  at  an  early  stage  the  prognosis  in 
childhood  is  good.  The  duration  of  treatment  may  be  estimated  at 
two  years  or  more  and  retention  of  a  fair  range  of  motion  may  be  ex- 
pected. Anchylosis  in  the  right-angled  position  does  not,  however, 
seriously  inconvenience  the  patient,  provided  the  cure  is  absolute. 
The  loss  of  growth  is  less  than  when  the  epiphysis  at  the  shoulder  is 
destroyed  and  the  final  disproportion  in  size  depends,  of  course,  upon 
the  age  of  the  patient  and  upon  the  degree  of  function  that  is  preserved. 

Fig.  244. 


f 


Tuberculous  disease  of  the  elbow  joiut,  the  stage  of  recovery. 


Operative  Treatment. — ^^In  some  instances  it  is  possible  to  remove 
small  foci  of  disease  from  the  humerus,  or  from  the  ulna,  before  the 
joint  is  involved.  The  position  of  the  disease  may  be  indicated  by 
sensitiveness  or  swelling  and  in  older  subjects  a  Roentgen  picture  may 
demonstrate  its  position  accurately. 

Excision  of  the  Elbow. — Excision  is  often  advisable  in  adoles- 
cent or  adult  life,  because  by  this  procedure,  in  most  instances,  the 
disease  may  be  cured  in  a  definite  time  and  because  a  movable  joint 
may  be  assured. 

Oschman  has  recently  investigated  the  final  results  of  the  operation 

23 


354     DISEASES  OF  ARTICULATIONS  OF   UPPER  EXTREMITY. 

performed  on  this  class  at  Kocher's  ^  clinic  at  Berne,  1872-1897.  In 
forty  of  forty-five  cases  the  operation  was  performed  for  tuberculous 
disease.  There  were  no  deaths  referable  to  the  operation.  Of  the 
entire  number  of  cases,  fifteen  were  dead,  but  eleven  of  these  survived 
the  operation  for  from  five  to  twenty  years.  Eight  of  the  deaths  were 
due  to  tuberculosis,  two  to  other  causes  and  in  five  the  cause  of  death 
was  unknown.  In  ninety-six  per  cent,  of  the  cases  the  local  disease  was 
cured.  In  sixty-eight  per  cent,  of  the  cases  the  patients  were  able  to 
use  the  limb  at  hard  labor  and  in  the  others  it  was  efficient  for  light 
work.  In  six  cases  there  was  subluxation  or  luxation,  in  five  the  joint 
was  not  firm.  In  fifty-nine  per  cent,  the  motions  were  practically 
normal.  In  eleven  per  cent,  the  joint  was  anchylosed.  The  Kocher 
method  of  exploring  and  excising  the  joint  which  was  employed  in 
the  majority  of  these  cases  has  the  advantage  of  sparing  the  muscu- 
lar attachments  and  affording  an  opportunity  for  inspection  of  the 
interior. 

The  incision  begins  upon  the  outer  aspect  of  the  humerus,  from 
three  to  six  cm.  above  the  line  of  the  joint  and  is  carried  directly 
downward  over  the  head  of  the  radius,  passing  in  the  interval  between 
the  extensor  muscles  of  the  arm  in  front  and  the  anconeus  behind.  It 
is  then  carried  inward  and  downward  across  the  back  of  the  forearm 
to  a  point  from  four  to  six  cm.  below  the  tip  of  the  olecranon,  then 
upward  for  two  cm.  on  the  inner  side  of  the  ulna.  Thus  the  mus- 
cular insertions  are  spared.  The  olecranon  process  is  then  divided 
and  turned  upward  and  the  joint  is  exposed.  If  a  complete  excision 
is  to  be  performed  the  olecranon  is  separated  from  its  muscular  at- 
tachments and  the  periosteum  if  possible.  The  part  must  be  sup- 
ported until  the  repair  is  complete,  and  in  the  after-treatment  lateral 
support  by  means  of  a  light  jointed  brace  will  add  to  the  comfort  of 
the  patient  and  prevent  distortion. 


Tuberculous  Disease  of  the  Wrist  Joint. 

Disease  of  the  wrist  joint  is  very  uncommon  in  childhood.  In  a 
total  of  3,105  cases  of  tuberculous  disease  treated  in  the  Out-patient 
Department  of  the  Hospital  for  Ruptured  and  Crippled  during  the  past 
five  years,  98  were  of  the  upper  extremity  and  in  but  four  of  these  was 
the  wrist  joint  involved.  Of  43  cases  in  which  the  joint  was  resected 
by  Oilier,  the  youngest  patient  was  thirteen  years  of  age. 

Of  990  cases  of  disease  of  the  joints  in  childhood,  reported  by 
Karewski,  the  wrist  was  involved  in  31.- 

Disease  of  the  wrist  in  older  subjects  is  less  infrequent,  although  at 
all  ages  it  is  rare  as  compared  with  disease  in  other  joints.  Tubercu- 
lous disease  of  the  metacarpus  and  phalanges  (spina  ventosa),  is,  how- 
ever far  more  common. 

1  Archiv  f.  Klin.  Chir.,  Bd.  60,  H.  2,  1900. 
^Chir.  Krank.  des  Kindei'saltei"s,  Berlin,  1894. 


TUBERCULOUS  DISEASE  OF  THE   WRIST  JOINT. 


355 


Age  at   Incipiency  of   Disease  at  the  Wrist  Joint  in  18   Consecu- 

,TivE  Cases  Treated  at  the  Hospital  for  Euptured 

AND  Crippled. 

1 

1 

1 


2  years 

old 

6      '' 

9      " 

12      " 

14      " 

16      " 

17      '' 

90 

u 

{,  f 

L  ( 

2 

'?5 

i  t. 

2 

'>f; 

i  {. 

2 

97 

1  i 

1 

Total 

T8 

Males  11,  females  7  ;  right  12,  left  6. 

Symptoms. — The  symptoms  of  tuberculous  disease  of  the  wrist  are 
as  in  other  situations  pain,  local  swelling  and  sensitiveness,  limitation 
of  motion,  caused  by  muscular  spasm  and  atrophy.  In  advanced  cases 
the  hand  is  usually  flexed  somewhat  upon  the  arm. 

Treatment. — The  treatment  of  this,  as  of  other  joints,  is  functional 
rest,  with  support  in  the  attitude  in  which  anchylosis  or  limitation  of 

Fig.  245. 


Tuberculous  disease  of  tlie  carpus. 

motion  will  cause  the  least  inconvenience.  A  light  plaster  bandage 
extending  from  the  elbow  to  the  tips  of  the  fingers,  applied  over  a 
flannel  bandage  drawn  as  tight  as  the  comfort  of  the  patient  will  per- 
mit, is  a  satisfactory  support ;  or  a  leather  splint  or  other  form  of  ap- 
pliance may  be  used.  The  hand  should  be  held  in  an  attitude  of 
moderate  dorsal  flexion,  which  will  permit  the  flexor  muscles  to  close 
the  fingers  easily  if  the  wrist  becomes  fixed  by  the  disease.  If  flexion 
deformity  is  present  it  should  be  corrected  by  degrees,  with  each  appli- 
cation of  the  bandage,  until  the  desired  attitude  is  attained.  (Fig.  247.) 
The  flannel  bandage  exercises  a  certain  amount  of  compression  upon  the 
wrist  which  seems  to  be  of  benefit,  and  in  certain  instances,  this  com- 
pression and  fixation  may  be  still  further  increased  by  the  application 
of  adhesive  plaster.  When  the  disease  of  the  joint  is  quiescent,  or  in 
the  stage  of  recovery,  the  bandage  or  splint  may  be  shortened  to  allow 
the  patient  to  use  the  fingers. 

Prognosis. — The   prognosis    as    regards    function  in  cases  treated 
promptly  in  childhood  should  be  good.     In  the  adult  cases,  wrist-joint 


356     DISEASES  OF  ARTICULATIONS  OF   UPPER  EXTREMITY. 

disease  seems  to  be  very  often  complicated  by  disease  of  the  lungs, 
thus  the  prognosis  as  to  life  is  often  bad.  In  this  class  of  cases  early 
excision  is  usually  recommended,  with  amputation  as  a  final  resort. 

Fig.  246. 


Tuberculous  disease  of  the  left  wrist  joint.  The  irregularity  and  the  diminished  size  of  the  carpal 
bones  indicate  the  extent  of  the  destructive  process.  The  patient,  the  mother  of  the  child  (Figs. 
10-11)  with  Pott's  disease,  died  within  a  year  of  tuberculosis  of  the  lungs. 

Spina  Ventosa. 

Central  disease  of  the  long  bones  of  the  foot  and  hand  is  the  mosfc 
common  form  of  tuberculous  osteomyelitis.  The  marrow  is  the  seat 
of  the  disease  and  caseous  degeneration  is  common.  While  the  corti- 
cal substance  is  destroyed  from  within  it  is  often  replaced  in  part  by 
a  formation  of  periosteal  bone  from  without,  which  in  turn  may  be 
destroyed  by  the  advancing  disease.  In  the  early  cases  the  affected 
bone  is  enlarged,  spindle-shaped,  and  is  somewhat  sensitive  to  pressure. 
At  this  stage  repair  may  take  place  with  but  little  ultimate  change 
from  the  normal,  but  in  many  instances  the  bone  is  perforated  and  in 
part  destroyed,  the  neighboring  joint  is  involved  and  the  finger  be- 
comes stunted  and  distorted. 

In  159  cases  tabulated  by  Karewski,^  the  metacarpal  bones  were 
diseased  in  65  instances — the  phalanges  in  57 — the  metatarsal  bones 
in  29 — the  phalanges  of  the  toes  in  8.     In  a  number  of  instances  sev- 

1  Chir.  Krank.  des  Kindensalters,  Berlin,  1894. 


SPINA    VENTOSA.  357 

eral  of  the  bones  and  larger  joints  were  involved  (159  cases  in   135 
patients). 

The  disease  is  more  common  in  the  early  years  of  life,  84  of  the  135 
patients  being  four  years  of  age  or  less,  38  of  these  being  less  than  two. 

Fig.  247. 


Treatment  of  tuberculosis  of  the  wrist  joint  by  plaster  of  Paris,  showing  the  proper  attitude. 

Spina  ventosa  of  the  phalanges  may  be  treated  by  rest  and  compres- 
sion, and  both  splinting  and  compression  may  be  exercised  by  adhesive- 
plaster  strapping.     If  the  joint  is  involved,  amputation  of  the  finger 

Fig.  248. 


Tuberculous  disease  of  the  wrist  and  knee  joints  showing  the  characteristic  deformities  in 
neglected  cases  of  a  severe  type. 

may  be  indicated  because  of  the  distortion  and  loss  of  growth  that  may 
be  expected.  Tuberculous  disease,  limited  to  a  single  bone  of  the  car- 
pus, or  metacarpus,  may  be  treated  by  operative  removal  of  the  disease. 


358     DISEASES  OF  ARTICULATIONS  OF   UPPER  EXTREMITY. 

Periarthritis  of  the  Shoulder. 

Under  the  title  of  scapulo-humeral  periarthritis,  Duplay  ^  in  1872 
described  a  painful  aifection  of  the  shoulder  induced  by  traumatism, 
dependent  upon  an  inflammation  of  the  bursa  lying  between  the  del- 
toid and  the  supra-  and  infra-spinatus  muscles  and  the  coraco-acroraial 
ligament.  But  under  this  title  are  now  included  a  number  of  affections 
that  cause  similar  symptoms  in  which  it  would  appear  that  the  interior 
of  the  joint  is  not  involved. 

Symptoms. — In  a  typical  case  of  so-called  periarthritis,  the  patient 
complains  of  a  dull  pain  about  the  joint  and  sensitiveness  to  pressure 
just  below  the  acromion  process  or  over  the  bicipital  groove.  The 
pain  is  increased  by  motion,  particularly  by  abduction  or  by  rota- 
tion of  the  arm.  In  mild  cases,  only  extensive  motion  causes  pain, 
but  in  most  instances  there  is  a  constant  sensation  of  discomfort  which 
is  increased  to  acute  pain  by  sudden  movements  or  jars.  The  part  be- 
comes sensitive  to  pressure  so  that  the  patient  avoids  lying  on  the 
shoulder  at  night.  In  certain  instances  the  pain  may  radiate  down  the 
arm  and  there  may  be  weakness  and  numbness  of  the  fingers.  Grad- 
ually the  passive  movements  of  the  joint  are  diminished  in  range,  and 
atrophy  of  the  shoulder  muscles  appears. 

These  symptoms  usually  pass  as  rheumatism,  but  there  is  no  fever, 
no  involvement  of  other  joints,  no  swelling,  and,  as  a  rule,  no  general 
sensitiveness  to  pressure,  as  is  usual  when  the  synovial  membrane  of 
the  joint  is  affected.  In  certain  instances  these  symptoms  follow  injury, 
or  exposure  to  cold  or  they  appear  without  apparent  cause.  In  one 
class  of  cases  the  symptoms  may  be  due  to  an  inflammation  of  the  sub- 
deltoid bursa,  as  in  the  cases  originally  described  by  Duplay  ;  in  others 
to  a  TEXO-SYNOViTis  of  the  biceps  tendon,  that  may  extend  to  the  sur- 
rounding parts.  This  is  suggested  by  local  sensitiveness  at  the  bicipital 
groove,  and  by  the  creaking  sensation  at  this  point  when  the  muscle 
is  in  use.  Or  the  symptoms  may  be  due  to  neuritis  affecting  the  cir- 
cumflex nerves,  as  suggested  by  Amidon.^  It  is  probable  also  that  the 
nerves  in  the  neighborhood  of  the  joint  may  be  secondarily  implicated 
in  an  inflammation  of  bursse,  or  directly  injured  by  the  original  trauma- 
tism, if  such  preceded  the  symptoms.  It  is  also  possible  that  the 
bursitis  may  have  been  a  sequel  of  gonorrhoea  or  of  other  infectious 
disease. 

Treatment. — During  the  acute  and  painful  stage  the  part  should  be 
kept  at  rest.  Cautery  may  be  applied  and  the  joint  should  be  enclosed 
in  adhesive  plaster  strapping,  and  if  the  weight  of  the  limb  causes 
discomfort,  it  should  be  supported.  In  certain  instances  tension  on 
the  sensitive  part  may  be  relaxed  by  supporting  the  arm  in  an  attitude 
of  abduction.  When  the  acute  symptoms  have  subsided  passive  move- 
ments, massage  and  static  electricity  are  of  service.  Voluntary  exer- 
cises should  be  employed  when  they  no  longer  aggravate  the  symptoms. 

'  Archiv  Generale  de  Med.,  Paris,  1872. 
2  Am.  Medico-Surg.  Bull.,  March  21,  1896. 


SPRAIN  OF  THE   WRIST.  359 

In  the  cases  of  long  standing  in  which  motion  is  very  much  restricted, 
apparently  by  adhesions  without  the  joint,  passive  movements  under 
anaesthesia  may  be  of  benefit.  In  such  cases  it  may  be  well  to  sup- 
port the  limb  for  a  time  in  the  abducted  attitude  to  prevent  the  for- 
mation of  the  adhesions.  Afterwards,  passive  motion,  massage  and 
exercises  may  be  employed.  If  these  cases  are  treated  carefully  in 
the  early  stage,  recovery  is  usually  rapid,  but  if  neglected  the  symptoms 
may  persist  indefinitely. 

Chronic  Bursitis. 

Chronic  bursitis  at  the  shoulder  joint  is  comparatively  infrequent. 
The  bursse  most  often  involved  are  the  coracoid,  the  sub-scapular  and 
the  deltoid.  Of  these  the  last  is  the  most  often  involved.  Sixteen 
cases  have  been  reported  by  Blauvelt,'  and  three  others  by  Ehrhardt.^ 
The  enlarged  bursa  forms  a  fluctuating  swelling  most  evident  on  the 
anterior  and  outer  aspect  of  the  shoulder,  the  symptoms  being  discom- 
fort, weakness  and  limitation  of  motion  of  the  arm.  The  disease  is 
usually  tuberculous  in  character  and  it  should  be  treated  by  incision 
or  by  complete  removal  of  the  sac,  if  possible. 

Sprain  of  the  Wrist. 

This  is  a  very  common  accident.  The  most  eifective  treatment  is 
the  adhesive-plaster  strapping  applied  about  the  metacarpus,  wrist  and 
lower  half  of  the  arm.  If  the  pain  on  motion  is  severe,  sufficient 
plaster  is  applied  to  splint  the  part  and  to  limit  movement  to  the  point 
of  comfort.  If  the  injury  is  of  a  slighter  grade  the  compression  and 
support  of  a  single  layer  of  plaster  is  usually  sufficient.  This  dressing 
prevents  injury  and  yet  it  allows  a  certain  degree  of  functional  use  which 
is  the  most  eifective  means  of  restoring  a  joint  to  its  normal  condition, 
by  hastening  the  absorption  of  the  effused  material  within  and  without 
the  joint. 

Chronic  Sprain. — Persistent  weakness  and  stiffness  may  follow 
treatment  of  a  sprain  by  splints,  or  when  for  any  reason  disuse  of 
function  has  been  long  continued.  In  many  instances,  however, 
the  sprain  was  in  reality  a  fracture  or  displacement.  All  chronic 
sprains,  therefore,  should  be  examined  by  means  of  the  X-ray  in 
order  that  the  presence  or  absence  of  more  extensive  injury  may  be 
determined. 

The  treatment  is  similar  to  that  of  the  acute  sprain,  protection  from 
injury,  and  functional  use  to  the  extent  of  which  the  part  is  capable. 
With  this,  massage,  hot  air  and  electricity  or  other  form  of  local  stimu- 
lation may  be  employed  with  advantage.  The  same  treatment  is  indi- 
cated when  the  joint  is  stiff  and  painful  as  the  result  of  rheumatism  or 
other  inflammation,  provided  the  stage  of  recovery  has  been  reached. 

1  Beitrage  zur  Klin.  Chir.,  Bd.  22. 
2Archivf.  Klin.  Chir.,  Bd.  60,  1900. 


360     DISEASES  OF  ARTICULATIONS  OF  UPPER  EXTREMITY. 

Acute  Teno -Synovitis. 

Teno-synovitis  is  common  at  the  wrist  joint.  It  is  usually  induced  by 
strain  or  over-use  of  a  muscle  or  set  of  muscles.  Movements  of  the 
muscles  that  are  involved  cause  discomfort  and  there  is  usually  local 
sensitiveness  and  a  creaking  sensation  on  palpation  over  the  affected 
tendon  sheath.  The  adhesive-plaster  strapping,  so  applied  as  to  exert 
compression  and  to  prevent  the  motion  that  causes  discomfort,  is  the 
most  effective  treatment. 

Chronic  teno-synovitis,  causing  progressive  enlargement  of  a  tendon 
sheath  with  accompanying  symptoms  of  weakness  and  discomfort,  is 
usually  tuberculous  in  character.  In  such  cases  the  diseased  part 
should  be  promptly  removed. 


CHAPTER    XIII. 

CONGENITAL  AND  ACQUIRED  AFFECTIONS  LEADING 
TO  GENERAL  DISTORTIONS. 

Rhachitis. 

Synonym. — Rickets. 

Rhachitis  is  a  constitutional  disease  of  infancy  caused  by  defective 
nutrition,  of  which  the  most  marked  efiPect  is  distortion  of  the  bones. 

Etiology. — The  predisposing  cause  is  constitutional  weakness.  This 
may  be  inherited,  or  it  may  be  the  direct  effect  of  illness,  but  most 
often  it  is  the  result  of  improper  hygienic  surroundings,  particularly 
lack  of  sunlight,  damp  rooms,  over-crowding  and  defective  ventilation. 
The  direct  cause  of  the  disease  is  improper  nourishment.  In  most  in- 
stances this  is  due  to  the  substitution  of  artificial  food  for  the  mother's 
milk,  in  others  to  improper  diet  after  the  infant  is  weaned  ;  in  rare 
cases  it  may  be  the  result  of  prolonged  lactation,  or  it  may  be  caused 
by  the  defective  quality  of  the  mother's  milk.  The  disease  therefore 
begins  usually  between  the  ages  of  six  and  eighteen  months,  although 
it  is  by  no  means  confined  to  these  limits.  In  most  instances  improper 
surroundings  and  improper  nourishment  are  combined  in  the  causa- 
tion of  the  disease  ;  thus  rhachitis  is  relatively  common  in  large  cities. 
At  the  Hospital  for  Ruptured  and  Crippled  the  most  extreme  cases 
are  observed  among  the  Italian  and  the  colored  children.  The  former 
are  usually  nursed  but  are  improperly  fed  after  weaning,  while  the 
latter,  if  nursed  at  all,  are  usually  allowed  a  mixed  diet  even  during 
the  early  months  of  life. 

Pathology. — The  manifestations  of  a  disease  dependent  upon  im- 
paired nutrition  are  of  course  general  in  character.  In  rhachitis  there 
is  a  mild  degree  of  anaemia,  and  a  general  weakness  and  relaxation  of 
the  voluntary  and  involuntary  muscles.  As  a  result  the  circulation  is 
impaired  and  the  power  of  assimilation  is  diminished,  thus  congestion 
and  enlargement  of  the  internal  organs,  intestinal  catarrh,  bronchitis 
and  the  like,  are  common  accompaniments  of  the  disease.  The  most 
marked  and  characteristic  changes  are  found  in  the  bones ;  these  con- 
sist in  a  diminution  of  the  earthy  substances  and  in  overgrowth  of 
osteoid  tissue. 

"  The  essential  features  of  the  morbid  process  are,  first,  an  exagger- 
ation of  the  processes  immediately  preparatory  to  the  development  of 
true  bone  ;  secondly,  an  imperfect  conversion  of  this  preparatory  tissue 
into  true  bone  ;  and  thirdly,  a  great  irregularity  of  the  whole  process." 
(Erichsen.) 


362 


AFFECTIONS  LEADING  TO  GENERAL  DISTORTIONS. 


On  section  of  a  rhachitic  bone  it  will  be  noted  that  the  periosteum 
is  increased  in  thickness,  and  is  more  or  less  adherent  to  the  under- 
lying softened  and  spongy  tissue.  The  medullary  canal  is  enlarged 
and  its  contents  are  abnormally  vascular.  The  epiphyseal  cartilage, 
normally  a  thin  bluish  line,  is  much  increased  in  thickness.  It  appears 
to  be  swollen  and  infiltrated,  and  it  has  lost  its  former  translucency. 
Microscopical  examination  at  this  point,  where  growth  is  most  active, 
shows  marked  irregularity  in  size  and  shape  of  the  columns  of  carti- 
lage cells ;  the  zone  of  calcification  is  lacking  or  is  ill-defined,  and 
masses  of  cartilage  cells  are  found  unchanged  in  what  should  be  the 

area  of  true  bone.    The  same 
Fig.  249.  irregularity  of  line  and  shape 

is  observed  in  the  medullary 
spaces  of  the  newly  formed 
osteoid  tissue. 

As  a  direct  result  of  the 
changes  that  have  been  de- 
scribed, the  epiphyseal  junc- 
tions are  enlarged  and  the 
shafts  of  the  bones  are  thick- 
ened by  the  formation  of 
osteoid  tissue  beneath  the 
periosteum.  The  indirect 
effects  of  the  disease,  and  of 
the  weakness  that  it  causes, 
are  deformities,  the  nature  of 
which  will  be  indicated  under 
the  heading  of  symptoms. 
The  stage  of  weakness  is 
followed  by  that  of  repair, 
which  sometimes  goes  on 
with  great  rapidity  ;  the 
softened  bones  become  ab- 
normally hard,  "eburnated," 
and  premature  solidification 
at  the  epiphyseal  junctions 
may  be  one  of  the  more  re- 
mote results  of  the  disease,  that  accounts  in  part  for  the  dwarfing  of 
the  stature,  observed  as  one  of  the  final  results  of  severe  rhachitis. 

Symptoms. — As  the  disease  is  the  effect  of  imperfect  assimilation 
its  more  pronounced  symptoms  are  preceded  by  those  of  indigestion, 
such  as  flatulence,  constipation  and  the  like.  Profuse  perspiration, 
especially  about  the  head,  and  restlessness  at  night  are  common  symp- 
toms. Teething  is  often  delayed  or  is  irregular.  The  infant  is  slow 
in  its  movements  and  makes  little  effort  to  stand  or  to  walk  at  the 
usual  time,  and  if  the  disease  is  active,  the  affected  parts  may  be  sen- 
sitive to  pressure. 

Deformities. — The  deformities  are  in  part  due  to  the  direct  effect  of 


General  rhachitic  deformities,  showing  distortions 
of  the  arms. 


DEFORMITIES  OF  RHACHITIS. 


363 


the  disease.  One  of  the  earliest  and  most  constant  evidences  of  rha- 
chitis  is  the  enlargement  about  the  epiphyses,  an  enlargement  caused 
in  part  by  the  direct  hypertrophy,  and  in  part  by  pressure  upon  the 
softened  tissues.  The  enlargements  at  the  junctions  of  the  ribs  and  the 
costal  cartilages,  the  "ehachitic  rosary,"  and  at  the  wrists  and  ankles, 
"double  joints,"  are  almost  invariably  present  in  well-marked  cases. 
The  more  general  distortions  are  in  part  the  effect  of  atmospheric  pres- 

FiG.  250. 


Chondrodystrophia  of  slight  degree  contrasted  with  ordinary  rhachitis,  in  sisters.  1.  Chondro- 
dystrophia.  Broad,  short,  very  flexible  hands,  trunk  disproportionately  long — knock  knees.  Age  53^ 
years,  height  30^^  inches  ;  normal  height  40  inches.  2.  Rhachitis,  bow  legs,  age  4  years  ;  height  32J^ 
inches  ;  normal  height  36  inches. 


sure,  in  part  the  effect  of  the  force  of  gravity  and  habitual  postures, 
and  in  some  instances  muscular  action  or  injury  may  deform  the  soft- 
ened bones.  These  deformities  differ  greatly  according  to  the  time  of 
onset  of  the  disease,  and  with  its  duration  and  severity.  The  head 
may  be  long  and  oblong  in  shape,  or  rectangular,  "  caput  quad- 
RATUM,"  and  it  sometimes  presents  prominences  in  the  frontal  and 
parietal  regions  due  to  thickening  of  the  bones,  and  on  the  posterior 
aspect  depressed  and  softened  areas,  "  craniotabes."    The  fontanelles 


3()4  AFFECTIONS  LEADING   TO   GENERAL  DISTORTIONS. 

are  abnormally  large  and  they  may  remain  open  long  after  the  usual 
time  of  closure. 

The  thorax  is  compressed  from  side  to  side,  the  compression  being 
most  marked  in  the  middle  region  where  the  ribs  have  the  longest 
cartilages  and  the  least  direct  support.  As  secondary  results,  the  back 
of  the  chest  is  flattened  and  the  sternum  is  thrust  forward  forming  the 
PIGEOX  BEEAST.  The  lowcr  ribs  are  everted  to  accommodate  the  dis- 
tended abdomen,  "  pot  belly."  In  well-marked  cases  the  rhachitic 
chest  presents  two  distinct  grooves,  one  transverse  in  the  axillary  line, 
"  HAREisox's  GROOVE,"  and  the  other  passing  upw^ard  by  the  side  of 
the  rhachitic  rosary.  These  deformities  are  in  great  degree  caused  by 
atmospheric  pressure,  but  they  are  increased  if  the  child  assumes  the 
sitting  posture  habitually.  In  this  attitude  the  body  is  inclined  for- 
ward, the  clavicles  are  distorted  and  the  spine  is  bent  into  a  more  or 
less  rigid  posterior  curve,  most  marked  in  the  lower  dorsal  and  lumbar 
regions,  the  "  rhachitic  spixe."  Less  often  there  may  be  a  lateral 
deviation  or  scoliosis. 

The  arms  may  be  distorted  by  the  efforts  of  the  child  to  support  the 
body  in  the  sitting  posture,  or  by  active  exertion,  as  in  creeping.  (Fig. 
249.)  Occasionally  the  deformities  may  be  localized  at  the  elbows,  and 
sufficiently  marked  to  merit  the  name  cubitus  varus  or  valgus,  cor- 
responding to  genu  valgum  or  varum  ;  or  the  principal  distortion  may 
be  a  dorsal  convexity  of  the  lower  extremity  of  the  radius. 

The  bones  of  the  lower  extremity  are  often  distorted,  primarily  by 
the  habitual  postures  assumed  in  sitting  or  creeping  and  these  defor- 
mities are  usually  exaggerated  when  the  erect  attitude  is  assumed.  In 
some  instances  it  would  appear  that  the  femoral  necks  are  twisted  back- 
wards somewhat ;  this  distortion  may  explain  in  part  the  limitation  of 
inward  rotation  that  is  sometimes  observed  in  rhachitic  children.  The 
changes  in  the  pelvis  are  of  special  interest  to  the  obstetrician.  These 
are  essentially  an  increase  in  the  sacro- vertebral  prominence,  due  to  the 
forward  and  downward  displacement  of  the  sacrum,  an  abnormal  ex- 
pansion of  the  ilia,  caused  by  pressure  of  the  abdominal  contents  and, 
in  some  instances,  a  decrease  of  the  lateral  diameter,  an  effect  of  the 
pressure  of  the  femora  upon  the  yielding  bone. 

In  the  milder  type  of  rhachitis  in  older  children,  who  walk,  the  defor- 
mities are  often  confined  to  the  trunk  and  lower  extremities.  In  such 
cases,  in  addition  to  the  changes  in  the  bones,  there  is  usually  a  promi- 
nent abdomen  and  increased  lordosis,  combined  with  slight  habitual 
flexion  of  the  thighs  and  lower  legs,  the  "  rhachitic  attitude." 

If  the  disease  is  of  sudden  onset  and  is  severe  and  general  in  its 
manifestations,  it  may  be  accompanied  by  pain,  by  sensitiveness  of  the 
affected  bones  and  by  such  weakness  of  the  lower  extremities  as  may 
simulate  paralysis,  rhachitic  pseudo-paralysis. 

It  is  probable,  however,  that  the  cases  in  which  the  pain  is  extreme, 
"  acute  rhachitis,"  are,  in  reality,  scurvy  or  scurvy  and  rhachitis  com- 
bined, scurvy  rickets  so-called. 

Rhachitis,  as  described,  is  the  type  ordinarily  seen  in  hospital  prae- 


TEEATMENT.  365 

tice  and  its  manifestations  are  unmistakable.  In  its  milder  form  it  is 
not  particularly  uncommon  among  the  children  of  the  well-to-do,  whose 
hygienic  surroundings  are  good.  In  such  cases  the  most  marked  symp- 
tom is  weakness.  The  child  is  often  fat  and  well  developed,  although, 
as  a  rule,  pale.  The  abdomen  is  somewhat  enlarged  and  slight  promi- 
nences at  the  epiphyseal  junctions,  particularly  at  the  wrists,  may  be 
made  out.  The  legs  appear  small  in  proportion  to  the  body  and  the 
ligaments  are  lax,  so  that  if  the  child  stands  the  feet  are  flat  and  as- 
sume the  attitude  of  valgus.  In  this  class,  in  which  the  child  is  said 
to  have  weak  ankles,  knock  knee  is  common. 

The  most  common  symptom  then  of  mild  rhachitis  is  the  failure  of 
the  child  to  attempt  to  walk  at  the  usual  time,  about  sixteen  months. 
If  a  child  who  is  not  ill  and  who  has  not  suffered  from  exhausting  dis- 
ease does  not  walk  at  two  years  of  age,  it  is  probably  rhachitic. 

Prognosis. — The  duration  of  the  progressive  stage  of  rhachitis  de- 
pends, of  course,  upon  the  age  of  the  patient  and  upon  the  treatment. 
In  cases  that  are  untreated  and  in  which  the  predisposing  causes  con- 
tinue, the  period  of  repair  may  be  delayed  for  several  years  or  longer, 
as  shown  by  the  fact  that  the  child  makes  little  effort  to  stand ;  but, 
in  most  instances,  the  rhachitic  child  begins  to  walk  at  some  time  dur- 
ing the  third  year  and  at  this  time  the  deformities  of  the  lower  ex- 
tremity, knock  knee,  bow  leg,  flat  foot  and  the  like,  usually  develop 
or  become  aggravated,  while  those  of  the  upper  extremity  may  become 
less  noticeable. 

The  deformities  of  rhachitis  tend  to  disappear  or  to  become  less 
marked  with  growth  ;  the  concavities  of  the  distorted  shafts  are  filled 
by  accretions  of  periosteal  bone,  which  is  again  absorbed  from  the  in- 
terior as  the  medullary  canal  straightens  itself.  The  thickened  dia- 
physes  and  enlarged  epiphyses  become  more  symmetrical  under  the 
influences  of  rapid  growth  and  increased  functional  activity,  but  traces 
of  severe  rhachitis  always  remain  and  many  of  the  more  noticeable  and 
permanent  distortions  of  the  trunk  and  of  the  lower  extremities  are 
due  to  this  cause. 

The  prognosis  as  to  the  outgrowth  of  rhachitic  deformities  depends 
upon  the  duration  and  the  severity  of  the  disease  and  upon  the  func- 
tion of  the  deformed  part.  Rhachitic  distortions  of  the  arms  almost 
always  disappear.  The  rhachitic  chest  is  rarely  seen  in  the  adoles- 
cent or  adult.  The  rhachitic  kyphosis  is  corrected  or  modified  when 
the  erect  posture  is  assumed,  but  rhachitic  scoliosis,  on  the  other  hand, 
usually  increases  with  the  growth.  Distortions  of  the  lower  extremi- 
ties may  entirely  disappear  and  in  most  cases  they  are  less  marked  in 
the  adult  than  in  the  child.  Stunting  of  the  growth  is  a  constant 
effect  of  severe  and  prolonged  rhachitis  ;  it  depends  in  part  upon  the 
arrest  of  development  during  the  active  stage  of  disease  and  in  part 
upon  the  changes  in  the  bones  that  cause  premature  consolidation  at 
the  epiphyses. 

Treatment. — The  treatment  of  rhachitis  consists  essentially  in  a  re- 
versal of  the  conditions  under  which  it  developed.     It  is  therefore  die- 


366  AFFECTIONS  LEADING   TO   GENERAL  DISTORTIONS. 

tetic,  hygienic  and  medicinal.  Deformity,  the  effect  of  the  disease, 
mav  be  prevented  by  guarding  the  weakened  bones  from  overstrain,  or 
it  may  be  remedied,  if  it  be  present,  by  manipulation  or  by  mechanical 
or  by  operative  treatment. 

The  more  detailed  treatment  of  rhachitis  may  be  found  in  works  on 
Pediatrics.  In  general,  the  diet  in  the  cases  developing  in  early  in- 
fancy should  be  of  milk,  especially  modified  according  to  the  need  of 
the  patient.  At  a  later  time,  corresponding  to  the  normal  period  of 
weaning,  the  diet  should  be  largely  animal,  to  the  exclusion  of  starchy 
food  ;  cream  and  fresh  butter  being  especially  valuable. 

The  patient,  protected  by  proper  woolen  underclothing,  should  pass 
as  much  time  as  possible  in  the  open  air  and  should  sleep  in  a  well- 
ventilated  room.  Daily  salt  baths  are  recommended  for  older  children 
and  regular  massage  of  the  extremities,  and  of  the  abdomen,  should 
be  employed.  Medicinal  treatment  is  of  secondary  importance.  The 
bowels  should  be  regulated  and  digestion  should  be  aided  by  proper 
remedies.  For  anaemia,  which  is  usually  present,  the  syrup  of  the 
iodide  of  iron  is  of  value ;  cod-liver  oil  serves  both  as  a  food  and 
medicine,  when  it  is  readily  assimilated.  It  is  unlikely  that  any  drug 
has  a  very  direct  influence  on  the  disease.  Phosphorus  in  doses  of 
1/200  to  1/100  of  a  grain  is  often  given  and  is  supposed  to  lessen  the 
abnormal  congestion  of  the  bones,  while  the  deficiency  of  lime  salts 
may  be  supplied  possibly,  by  the  administration  of  lime  in  some  form, 
the  syrup  of  the  lactophosphate  of  lime  being  a  favorite  prescription. 

The  prevention  of  deformity,  other  than  by  the  means  already  enu- 
merated, consists  in  preventing  habitual  postures  that  predispose  to 
deformity,  and  in  daily  massage  and  manipulative  correction  of  begin- 
ning distortions.  Young  infants  and  those  whose  bones  are  especially 
vulnerable  should  spend  much  of  the  time  in  the  reclining  posture. 
The  Bradford  frame,  or  similar  appliance,  is  especially  useful  in  the 
treatment  of  this  class  of  cases.  The  treatment  of  the  more  advanced 
deformities,  by  support  or  by  operation,  is  described  elsewhere. 

<'Late  Rickets." 

Late  rickets  is,  as  the  name  implies,  an  aifection  presenting  all  the 
characteristics  of  the  common  infantile  form.  This,  in  rare  instances, 
appears  in  later  childhood  or  even  in  adolescence;  in  some  cases  the 
affection  appears  to  be  a  continuation  or  recrudescence  of  the  infantile 
form  ;  in  others  no  history  of  a  preceding  affection  can  be  obtained.^ 

By  many  writers  the  term  late  rickets  is  improperly  used  to  explain 
the  deformities  of  adolescence,  genu  valgum,  coxa  vara  and  the  like, 
although  none  of  the  distinctive  signs  of  the  affection  may  be  present. 
Local  rickets  is  less  objectionable  as  applied  to  the  same  class  of  cases, 
although  pathological  specimens  present  little  evidence  of  actual  local 
disease. 

iDrewitt,  Trans.  Lond.  Path.  Soc,  Vol.  XXXIL,  1881.  Glutton,  St.  Thomas' 
Hosp.  Reports,  Vol.  XIV.,  1884. 


INFANTILE  SCORBUTUS.  367 


Foetal  Rhachitis. 


Synonyms. — Chondrodystrophia,  Achondroplasia. 

Cases  that  present  the  signs  of  what  appears  to  be  severe  general 
rhachitis  at  birth,  are  not  especially  uncommon.  The  trunk  is  dis- 
proportionately long  as  compared  to  the  stunted  limbs ;  the  head  is 
large,  the  chest  presents  a  pigeon-like  distortion  and  the  epiphyses  ap- 
pear to  be  generally^enlarged.  In  some  instances  the  back  is  curved 
into  a  rigid  kyphosis^r  scoliosis,  and  restricted  motion,  or  apparent 
fixation,  of  many  of  the  joints  may  be  present. 

Etiology  and  Pathology. — These  cases  were  formerly  supposed  to 
be  instances  of  intra-uterine  rhachitis  ;  chondrodystrophia  is  not  how- 
ever the  result  of  a  disturbance  of  nutrition,  it  is  due  apparently  to  a 
congenital  defect  in  the  bones  themselves  or  rather  of  the  original 
cartilage.  Rhachitis  is  characterized  by  hypertrophy  of  the  epiphyseal 
cartilages  and  by  delayed  ossification.  In  chondrodystrophia,  on  the 
contrary,  there  is  atrophy  of  the  epiphyseal  cartilages  and  abnormal 
rapidity  of  ossification.  On  section  of  a  bone  the  shaft  is  seen  to  be 
thickened  and  stunted,  the  epiphyses  are  enlarged  also  and  these  hyper- 
trophied  and  prematurely  ossified  segments  may  overhang  the  diminu- 
tive cartilage  that  intervenes. 

Chondrodystrophia,  or  an  affection  resembling  it,  is  sometimes  seen 
(Fig.  250)  in  a  very  mild  form  ;  the  appearance  of  the  child  suggests 
rhachitis,  but  the  stunting  of  the  growth  is  greater  than  is  ever  the 
result  of  rhachitis  of  corresponding  severity. 

Ceetixism, — Cretinism  may  cause  a  similar  dwarfing  of  the  stature, 
and  cretinism  may  be  combined  with  chondrodystrophia,  but  in  most 
instances  the  symptoms  of  mental  deficiency  that  accompany  cretinism, 
are  lacking  in  this  affection. 

Treatment. — The  treatment  of  so-called  foetal  rhachitis  consists  in 
regular  massage  and  manipulation  of  the  distorted  parts  and  of  the 
anchylosed  joints.  This  treatment  may  extend  over  several  years,  dur- 
ing which  the  limbs  and  back  must  be  protected.  Rest  on  the  Brad- 
ford frame  during  the  period  of  active  treatment,  is  advisable.  If 
congenital  cretinism  is  suspected,  the  administration  of  thyroid  extract 
would  be  indicated. 

Prognosis. — By  persistent  treatment  the  range  of  motion  in  the 
stiffened  joints  may  be  regained,  but  the  prognosis  is  bad.  The  patients 
present  in  later  years  the  abnormally  long  trunk  and  stunted  extremi- 
ties that  were  present  at  birth. 

Infantile  Scorbutus. 

Synonyms. — Scurvy,  Scurvy  Rickets. 

Scurvy  in  infancy,  as  at  other  periods  of  life,  is  a  constitutional  dis- 
ease, dependent  upon  impaired  nutrition,  caused  apparently  by  the 
deprivation  of  proper  food.  The  disease  was  originally  described  by 
Smith  and  Barlow  as  scurvy  rickets,  but  it  may,  and  often  does,  occur 
independently  of  the  latter  affection. 


368  AFFECTIONS  LEADING   TO   GENERAL  DISTORTIONS. 

Pathology. — The  pathological  changes  most  often  found  in  cases  of 
the  advanced  type  are  hemorrhages  beneath  the  mucous  membranes 
and  the  periosteum.     Separation  of  the  epiphyses  may  occur. 

Symptoms. — The  disease  is  most  often  observed  in  bottle-fed  infants 
from  six  to  eighteen  months  of  age.  In  some  instances  the  patients 
are  evidently  ill-nourished,  but  in  others  they  may  appear  to  be  in 
good  condition.  The  early  symptoms  resemble  rheumatism.  The 
child  shows  evidences  of  discomfort  when  certain  joints  are  moved,  and 
as  the  disease  progresses  it  may  scream  whenever  it  is  turned  or  lifted. 
The  painful  joints  are  sensitive  to  pressure  and  they  may  be  somewhat 
enlarged,  but  local  heat  and  redness,  as  well  as  fever,  are,  as  a  rule, 
absent.  After  dentition  the  gums  may  be  swollen  and  spongy,  and 
hemorrhages  into  the  skin  or  beneath  the  mucous  membranes  may  oc- 
cur. In  extreme  cases  the  swelling  about  a  joint  due  to  effusion  of 
blood  and  accompanied,  it  may  be,  by  separation  of  the  epiphysis  may 
be  mistaken  for  the  symptoms  of  infectious  epiphysitis  or  even  for 
sarcoma. 

Treatment. — The  treatment  consists  primarily  in  the  regulation  of 
the  diet,  particularly  in  the  substitution  of  fresh  milk,  properly  modi- 
fied, for  the  patent  food  or  sterilized  milk  that  may  have  been  em- 
ployed. This  should  be  supplemented  by  orange  juice,  or  that  of  other 
fresh  fruit.  The  change  of  diet  usually  relieves  the  symptoms.  Dur- 
ing the  painful  stage  of  the  disease  complete  rest  in  the  horizontal  posi- 
tion on  a  pillow  or  frame,  may  be  indicated ;  later,  massage  of  the 
limbs  and  back  may  be  of  service  in  improving  the  nutrition,  and 
remedying  slight  deformity. 

Fragilitas  Ossium. 

Sjmonym. — Idiopathic  Osteopsathyrosis. 

There  are  many  conditions  that  cause  local  or  general  fragility  of 
the  bones  and  thus  an  increased  liability  to  fracture.  For  example, 
the  weakness  of  old  age,  sometimes  called  senile  rickets ;  the  atrophy 
caused  by  disuse  incidental  to  chronic  joint  disease,  or  the  weakness 
that  may  be  caused  by  certain  diseases  of  the  nervous  system.  Weak- 
ness of  the  bones  may  be  general  in  character,  as  when  it  is  the  re- 
sult of  osteomalacia  or  rhachitis. 

Idiopathic  fragility  or  osteopsathyrosis  is  of  congenital  origin.  The 
bones  appear  to  be  weak  simply  because  of  a  failure  in  the  formation 
of  periosteal  bone.  In  such  cases,  there  may  be  distortions  at  birth, 
apparently  caused  by  intra-uterine  fractures,  and  in  after  life,  fracture 
may  follow  the  slightest  accident  or  sudden  motion.  Blanchard  ^  has 
reported  a  case  in  which  there  were  seventy  distinct  fractures  between 
the  ages  of  two  months  and  twenty-seven  years.  A  similar  case  was 
for  many  years  under  treatment  in  the  Hospital  for  Ruptured  and 
Crippled.  For  a  part  of  the  time  the  bocly  and  trunk  were  inclosed 
in  a  plaster  of  Paris  casing,  to  prevent  the  fractures  that  followed  even 

'Trans.  Am.  Orth.  As.s'n,  Vol.  VI. 


OSTEOMALACIA. 


369 


ordinary  movements.  At  the  age  of  fourteen  the  strength  of  the  bones 
had  increased  sufficiently  to  enable  the  patient  to  walk  about  with  the 
support  of  braces,  but  he  was,  in  stature,  about  the  size  of  a  child  of 
seven  years. 

Fractures  in  this  class  of  cases  are  attended  with  but  little  pain. 
They  unite  slowly  with  but  a  small  callus.  It  is  practically  impossible 
to  prevent  a  certain  amount  of  deformity.  With  advancing  years  the 
liability  to  fracture  may  diminish,  but  as  a  rule  the  patient  is  disabled. 

The  treatment  is  pro- 
tective.    Massage  is  of  Fig.  251. 
service     in     improving 
nutrition.      Medication 
is  of  little  avail. ^ 

Osteomalacia. 

Synonym. — Mollitis 
Ossium. 

Osteomalacia  is  a  dis- 
ease of  an  inflammatory 
nature,  characterized  by 
an  absorption  of  the 
earthy  substances  (de- 
calcification) of  the 
bones  and  by  deformity. 
The  disease  is  one  of 
adult  life.  It  is  far 
more  common  among 
females  than  males,  and 
pregnancy,  in  about 
half  of  the  cases  that 
have  been  reported, 
seemed  to  be  the  excit- 
ing cause.  The  disease 
usually    begins    insidi-  osteomalacia. 

ously.     The  symptoms 

are  pain  on  motion  referred  to  the  pelvis  and  to  the  thighs.  This  is 
supposed  to  be  of  rheumatic  origin  until  the  character  of  the  affection 
is  made  evident  by  the  weakness  of  the  limbs  and  by  the  deformities. 
These  deformities  are  of  greater  interest  to  the  obstetrician  than  to  the 
surgeon,  for  when  the  affection  complicates  pregnancy,  the  distortion 
of  the  pelvis  may  be  so  great  as  to  prevent  normal  delivery. 

Osteomalacia  in  Childhood. — Three  cases  of  osteomalacia  in 
childhood  have  been  reported  by  Siegert,^  and  one  case  has  come  under 
my  observation.  The  patient,  one  of  twelve  living  children  of  healthy 
parents,  was  nursed  by  his  mother  for  the  usual  period,  and  until  the 

1  Porak,  Bui.  et  Mem.  de  la  Soc.  Obst.  et  Gyn.  de  Paris,  1890.     Salvetti,  Beitr.  zur 
Path.  Anat.  und  AUg.  Path.,  Bd.  XVI.,  1894. 
*Munch.  med.  Wochens.,  Nov.  1,  1898. 

24 


370  AFFECTIOyS  LEADING  TO   GENERAL  DISTORTIONS. 

age  of  four  years  he  appeared  to  be  perfectly  healthy.  At  this  time 
without  known  cause  general  weakness  of  the  lower  limbs  became  ap- 
parent, and  at  the  same  time  deformities  of  the  lower  extremities  de- 
veloped. At  the  age  of  six  years  he  was  unable  to  stand.  At  the 
present  time  the  condition  of  the  patient,  now  nine  years  of  age,  is 
shown  in  the  preceding  illustration.  There  is  no  evidence  of  rhachitis 
or  of  paralysis.  The  patient  has  never  suffered  from  pain  or  discom- 
fort. The  lower  extremities  are  somewhat  atrophied  from  disuse,  the 
bones  are  abnormally  flexible  and  are  distorted  to  a  moderate  degree. 
The  epiphyses  are  not  enlarged.     (Fig.  251.) 

Treatment. — As  the  etiology  of  the  affection  is  unknown,  treatment 
is  symptomatic  and  palliative. 

Osteitis  Deformans. 

This  disease  was  first  described  by  Paget  ^  in  1877.  It  is  a  chronic 
inflammatory  affection  of  the  bones,  characterized  by  hypertrophy  and 
softening.  "The  bones  enlarge,  soften,  and  those  bearing  weight 
become  unnaturally  curved  and  misshapen." 

Section  of  an  affected  bone  shows  it  to  be  markedly  increased  in 
size,  and  somewhat  in  length,  by  a  combination  of  rarefying  and  form- 
ative osteitis.  The  inner  layers  become  porous,  and  at  the  same  time 
new  bone  is  deposited  beneath  the  periosteum. 

The  disease  appears  to  be  confined  to  adult  life,  and  is  equally 
divided  between  the  sexes.  Although  but  a  single  bone  may  be  afi"ected, 
as  a  rule  the  lesion  is  symmetrical  and  more  general  in  its  area,  the 
bones  of  the  lower  extremity,  the  skull  and  the  spine  being  more  often 
involved.  Thus,  the  head  progressively  increases  in  size,  and  the  legs 
become  bowed.  If  the  spine  is  affected  it  bends  forward  forming  a 
long,  more  or  less  rigid,  kyphosis. 

Aside  from  the  deformities  and  the  characteristic  enlargement  of  the 
bones,  the  symptoms  are  not  marked.  At  times  complaint  is  made  of 
pain  usually  supposed  to  be  rheumatic  until  the  characteristic  changes 
in  the  bones  appear.  The  disease  is  extremely  chronic  in  its  course, 
and  as  a  rule  the  general  health  is  not  seriously  affected.  In  several 
instances  sarcoma  of  bone  finally  caused  death  many  years  after  the 
onset  of  the  disease.  Its  etiology  is  unknown,  its  treatment  is  palli- 
ative. 

Secondary  Hypertrophic  Osteo-Arthropathy.- 

Osteo-arthropathy  is  an  inflammatory  disease  of  the  bone  character- 
ized by  hypertrophy,  clubbing  of  the  fingers  and  effusion  into  certain 
of  the  joints.  The  hypertrophy  is  caused  by  a  deposition  of  layers  of 
bone  beneath  the  periosteum  of  the  metacarpal  and  metatarsal  bones, 
the  phalanges  and  the  distal  extremities  of  the  adjoining  bones  of  the 

1  Med.  Chir.  Trans.,  Vol.  40  and  Vol.  65,  1882. 

2 Marie,  Eevue  Medical,  Paris,  1890,  X.,  p.  1.  Bamburger,  "Wiener  klin.  Woch., 
N.  11,  1889.     Deutsche  Chir.,  L.  28,  1899. 


ACROMEGALIA.  371 

arms  and  legs.  Less  often  the  area  of  the  disease  is  more  extensive, 
involving  the  femora,  the  humeri  and  the  spine  even. 

Osteo-arthropathy  is  usually  a  complication  of  preexisting  chronic 
disease,  most  often  of  the  lungs.  The  patient  first  notices  clubbing  of 
the  terminal  phalanges  and  hypertrophy  of  the  finger  nails,  later  an 
increasing  enlargement  of  the  wrists  and  ankles  and  of  the  hands  and 
feet,  accompanied  by  discomfort,  sensitiveness  to  pressure  and  often  by 
effusion  into  the  neighboring  joints,  symptoms  that  would  be  classed 
as  rheumatic  were  it  not  for  the  evident  hypertrophy. 

The  clubbing  of  the  fingers  is  due,  in  part  at  least,  to  impairment 
of  the  circulation  and  the  connection  of  the  disease  of  the  bones  with 
that  of  the  lungs  has  suggested  the  theory  that  it  is  caused  by  the  ab- 
sorption of  toxines  and  that  its  etiology  is  similar  to  the  amyloid  hy- 
pertrophy of  the  internal  organs  that  sometimes  follows  chronic  disease 
of  bones  and  joints  attended  by  suppuration. 

The  treatment  is  symptomatic  and  as  the  affection  is  almost  always 
secondary  to  a  graver  disease,  but  little  is  known  of  its  outcome.  It 
is  certain,  however,  that  the  secondary  osteo-arthropathic  symptoms 
become  less  marked  or  may  even  disappear  as  the  patient  recovers  from 
the  original  disease  of  the  lungs  or  other  organs.  The  affection  is 
very  uncommon  in  childhood,  but  one  typical  case  having  been  recorded.^ 

Acromegalia. 

This  affection  is  also  characterized  by  progressive  enlargement  of  the 
hands  and  feet,  but  it  differs  from  osteo-arthropathy  in  that  all  the 
tissues  are  involved  in  the  hypertrophy.  The  hypertrophy  of  the  bone 
is  limited  to  the  epiphyseal  extremities  and  is  slight  compared  with 
that  of  the  soft  parts.  The  face  is  often  involved,  the  tissues  of  the 
nose,  lips  and  ears  being  enlarged  and  thickened,  together  with  the 
underlying  bones,  so  that  the  expression  is  very  markedly  changed. 

Acromegalia  is  common  among  those  of  gigantic  stature.  The  local 
hypertrophy  and  the  giganticism  both  being  due,  it  is  supposed,  to  dis- 
ease of  the  pituitary  gland. 

Diagnosis. — The  three  affections  that  have  been  described,  osteitis 
deformans,  osteo-arthropathy  and  acromegalia,  are  rare  diseases  and 
they  are  of  little  practical  interest  to  the  surgeon  other  than  from  the 
standpoint  of  diagnosis.  This  might  be  somewhat  difficult  if  the  pa- 
thological process  were  confined  to  a  single  bone  or  limb,  as  is  some- 
times the  case  in  osteitis  deformans. 

The  essential  characteristics  of  the  three  diseases  may  be  summarized 
as  follows:  In  osteitis  deformans  the  entire  bone  is  increased  in  size 
and  length,  and  because  of  the  coincident  weakening  of  its  structure,  it 
becomes  distorted  ;  the  skull  is  often  involved  but  the  hands  and  feet 
are  not  often  affected.  It  is  a  disease  of  middle  or  later  life  and  there 
are,  as  a  rule,  no  symptoms  other  than  those  due  to  the  local  changes 
in  the  bones. 

1  Whitman,  Pediatrics,  February  15, 1899. 


372  AFFECTIONS  LEADING   TO   GENERAL  DISTORTIONS. 

In  osteo-arthropathy  the  process  is  an  hypertrophy,  but  of  a  slight 
degree,  caused  by  deposition  of  periosteal  bone  especially  about  the 
distal  extremities  of  the  shafts  of  the  bones  adjoining  the  hands  and 
feet.  It  is  not  often  accompanied  by  the  weakness  or  the  deformity 
that  is  characteristic  of  the  preceding  affection  ;  the  skull  is  not  usually 
involved,  but  the  long  bones  of  the  hands  and  feet  are  thickened  so 
that  these  members  are  markedly  increased  in  size.  There  is  often 
coincident  discomfort  and  swelling  of  the  neighboring  joints.  As  a 
rule  the  local  affection  of  the  bones  is  secondary  to  chronic  disease 
of  the  lungs. 

In  acromegalia  the  marked  changes  are  hypertrophic  enlargements 
of  the  hands  and  feet  in  which  all  the  tissues  are  involved ;  the  hyper- 
trophy of  the  bones  is  most  marked  about  the  epiphyses,  the  diaphyses 
remaining  unaffected ;  thus  it  differs  from  the  preceding  disease,  in 
which  similar  enlargement  of  the  extremities  occurs.  The  head  is 
often  involved,  but  the  hypertrophy  is  of  all  the  structures  of  the  face, 
not  of  the  skull  as  in  osteitis  deformans. 

The  disease  appears  to  be  confined  to  early  adult  life  and  it  is  often 
preceded  or  accompanied  by  symptoms  of  a  general  nature,  headache, 
mental  impairment  and  the  like. 

The  changes  in  the  bones  characterizing  the  affections  may  be  easily 
demonstrated  by  means  of  the  Roentgen  pictures. 


CHAPTER    XIV. 

CONGENITAL   DISLOCATION  OF   THE   HIP    AND 
COXA  VARA. 

Congenital  Dislocation  at  the  Hip  Joint. 

Of  all  the  congenital  dislocations  or,  perhaps,  more  properly  mis- 
placements, that  of  the  hip  joint  is  by  far  the  most  common  and  the 
most  important. 

Statistics. — Congenital  dislocation  of  the  hip  is  much  more  common 
in  females  than  in  males.     In  671  cases  collected  from  different  sources 


Fig.  252. 


Congenital  dislocation  of  the  hip  showing  the  elongated  capsule  and  the  right  angled  relation  of  the 
neck  to  the  shaft  of  the  femur.     (William  Adams.) 

by  Lorenz,  589  (87.8  per  cent.)  were  in  females  and  82  (12.2  per  cent.) 
in  males.  Of  1,039  cases  seen  at  the  Polyclinic  in  Milan,  867  (83.4 
per  cent.)  were  in  females,  172  (16.6  per  cent.)  in  males.^  In  500 
cases  from  the  records  of  the  Hospital  for  Ruptured  and  Crippled,  in- 
'  Bernacchi,  Zeits.  Orth.  Chir.,  Vol.  II.,  p.  275. 


374  CONGENITAL  DISLOCATION  OF  THE  HIF. 

vestigated  for  me  by  Dr.  C.   P.  Flint,  413  (82.6  per  cent.)  were  in 
females  and  87  (17.4  per  cent.)  in  males. 

The  dislocation  is  more  often  unilateral  than  bilateral.  In  Lorenz' 
series  of  671  cases,  421  (64.4  per  cent.)  were  single  ;  225  of  the  right, 
196  of  the  left  side.  In  245  cases  (36.6  per  cent.)  the  displacement 
was  bilateral. 

Statistics  of  500  Cases  of  Congenital  Dislocation  of  Hip,  Eecorded 
AT  the  Hospital  for  Ruptured  and  Crippled. 

Males 87 17.40  per  cent. 

Females 413 82.60         " 

Total 500  100.00         " 

Eight  hip 135 27.66  per  cent. 

Left  hip 218 44.47         " 

Both 136 27.87         '< 

489  100.00         " 

Not  specified 11 

500 

Males. 

Right  hip 25 30.48  per  cent. 

Left  hip 32 39.04         " 

Both 2h 30.48         " 

^  100.00         " 

Not  specified 5 

"87 

Females. 

Right  hip 110 27.04  per  cent. 

Lefthip 186 55.69         " 

Both Ill 27.27         " 

407  100.00         " 

Not  specified 6 

4T3 

The  dislocation  at  the  time  when  the  patients  are  brought  for  treat- 
ment is  almost  always  posterior,  upon  the  dorsum  of  the  ilium ;  in 
other  instances  it  is  anterior,  so  that  the  head  of  the  bone  may  be  felt 
beneath  the  anterior  superior  spine.  It  is  possible  however  that  the 
primary  displacement  may  be  in  certain  instances  directly  upward. 

Patholog'y. — The  pathological  anatomy  of  the  dislocation  was  first 
clearly  demonstrated  by  Dupuytren  in  1826,  and  since  1890,  when  the 
open  operation  was  first  performed,  the  exact  relation  and  the  appear- 
ances of  the  different  components  of  the  joint  have  been  described  in 
detail  by  HofFa,  Lorenz  and  other  operators. 

The  condition  of  the  joint  varies  with  the  age  of  tlie  patient  and  the 
strain  and  friction  to  which  the  displaced  parts  have  been  subjected. 
In  early  infancy  it  may  be  assumed  that  the  head  of  the  bone  lies  in 
close  proximity  to  what  is,  in  some  instances,  a  practically  normal 
acetabulum  ;   in  others  to  one  that  is   somewhat  rudimentary,  often 


PATHOLOGY. 


375 


shallow  and  small,  sometimes  of  an  oval  but  usually  of  a  somewhat 
triangiilar  shape.  The  acetabulum  is  covered  with  normal  hyaline 
cartilage,  the  ligamentum  teres  is  present  and  the  capsule  is  of  nearly 
normal  structure.  At  a  later  time  when  the  joint  is  exposed  at  oper- 
ation at  the  age  of  five  or  more  years,  the  rudimentary  acetabulum  may 
be  partly  filled  with  cartilage,  fat  and  fibrous  tissue,  so  that  it  may  be 
almost  on  a  level  with  the  surrounding  bone.  As  a  rule,  however  a 
well-marked  ridge  indicating  its  posterior  and  upper  margin  can  be 
made  out  and  in  many  instances  it  appears  to  be  of  fair  size  and  depth. 
The  CAPSULE  is  elongated  to  accommodate  the  upward  dislocation  of  the 
femur.  It  is  hypertrophied,  especially  where  it  covers  the  upper  part 
of  the  head  of  the  bone,  and  it  is  often  drawn  into  a  shape  like  an 
hour  glass  ;  the  upper  part  con- 
tains the  head  of  the  bone,  the  Fig.  253. 
anterior  wall  is  drawn  tightly 
across  the  acetabulum,  forming 
at  its  upper  border  a  narrow  slit- 
like communication,  through 
which  the  ligamentum  teres 
passes,  if  it  be  present.  (Fig- 
252.)  The  interior  of  the  cap- 
sule is  in  part  lined  with  syn- 
ovial membrane,  and  it  often 
contains  more  synovial  fluid  than 
is  found  in  the  normal  joint. 

The  LIGAMENTUM  TERES,  al- 
though probably  present  at  birth 
in  a  large  proportion  of  the  cases, 
becomes  attenuated  and  ribbon- 
like with  the  increasing  elonga- 
tion of  the  capsule,  and  after  the 
age  of  five  years  or  at  the  time 
when  the  open  operation  is  per- 
formed, it  is  usually  absent. 
According  to  Lorenz  in  52  cases 
between  two  and  a-half  and  five  years  it  was  present  in  17  ;  in  48 
cases  beyond  the  age  of  five  years  it  was  present  in  but  4.  In  rare 
instances  it  may  be  hypertrophied.  In  ray  own  experience  the  liga- 
ment is  present  in  a  very  much  larger  proportion  of  the  cases,  although 
it  is  often  so  rudimentary  that  it  might  easily  be  overlooked. 

A  shallow  SECONDARY  ACETABULUM,  formed  in  part  by  the  direct 
pressure  of  the  head  of  the  bone  through  the  adherent  capsule,  and  in 
part  the  result  of  irritation  of  the  periosteum,  is  usually  found  upon  the 
ilium  (Fig.  253),  but  it  is  not  often  of  sufficient  depth  to  assure  a  secure 
support  for  the  head  of  the  femur ;  thus  its  upper  margin  gradually 
recedes  or  two  distinct  depressions  may  be  formed  one  above  the  other. 
The  upper  extremity  of  the  femur  is  usually  somewhat  atrophied. 
The  neck  is  often  shorter  than  normal,  and  its  angle  may  be  lessened, 


Congenital  dislocation  of  the  hip,  showing  the  orig- 
inal and  the  acquired  acetahula.    (Lokenz.) 


376 


CONGENITAL  DISLOCATION  OF  THE  HIP. 


and  in  many  instances  its  forward  inclination  is  increased.  The  head 
of  the  bone  may  be  nearly  normal  although  usually  it  is  somewhat 
flattened  on  its  inner  and  under  surface,  or  it  may  be  somewhat  conical 
in  shape,  or  again  compressed  from  side  to  side  to  an  almond  shape  or 
otherwise  distorted.  The  abnormalities,  in  part  congenital,  become 
more  marked  with  age,  and  in  adult  specimens  the  head  and  neck  of  the 
femur  may  be  so  atrophied  and  worn  away  that  it  has  little  semblance 
of  normal  contour.     (Fig.  254.) 

There  are  also  secondary  changes  in  the  bones  of  the  pelvis.     In 
unilateral  dislocation  the  pelvis  is  usually  somewhat  atrophied  on  the 

Fig.  254. 


Congenital  dislocation  of  the  hip  showing  the  depressions  in  the  ilium  and  the  final  effect  of  pressure 
and  friction  upon  the  femur.     (Adams.) 


affected  side,  and  a  lateral  inclination  of  the  spine  may  be  present. 
The  final  changes  in  the  pelvis  caused  by  the  bilateral  dislocation,  are 
more  important ;  its  inclination  is  increased,  the  lumbar  lordosis  is  ex- 
aggerated, the  sacrum  is  forced  forward  and  downward  so  that  the  an- 
tero-posterior  diameter  is  lessened  ;  the  tuberosities  of  the  ischia  are 
everted  and  the  transverse  diameter  of  the  pelvic  outlet  is  increased. 

The  long  muscles  of  the  thigh  are  sliortened,  while  those  attached 
about  the  trochanter  are  changed  in  direction  and  are  usually  length- 
ened. There  is  also  a  slight  general  muscular  atrophy  that  is  particu- 
larly marked  in  the  gluteal  group. 


ETIOLOGY. 


377 


The  changes  that  have  been  described  are  in  great  degree  secondary 
to  the  displacement.  They  are  in  part  congenital,  in  part  accommoda- 
tive and  in  part  due  to  the  influences  of  attrition  and  injury,  to  which 
the  abnormal  mobility  predisposes  ;  thus,  as  a  rule,  they  become 
more  marked  with  increasing  age,  and  in  some  of  the  adult  specimens 
but  little  resemblance  to  the  normal  parts  remains. 

As  a  rule,  congenital  dislocation  of  the  hip  is  not  accompanied 
by   defective  development  or  deformity  elsewhere :    although  cases 


Fig.  255. 


Fig.  256. 


Unilateral  dislocation  showing  the  inclination 
of  the  body  toward  the  shorter  leg. 


The  same  patient  before  operation,  showing 
the  abnormal  lordosis  and  rotation  of  the  pel- 
vis.    (See  Figs.  270,  271. ) 


are  sometimes  seen  in  which  a  general  laxity  of  ligaments  is  present 
or  in  which  the  dislocation  may  be  one  of  a  series  of  deformities  and 
malformations. 

Etiology. — Nothing  positive  is  known  of  the  etiology  of  the  dislo- 
cation. In  a  small  proportion  of  the  unilateral  cases  it  may  be  due  to 
violence  at  birth,  but  the  fact  that  nearly  85  per  cent,  of  the  patients 
are  females  makes  it  evident  that  the  primary  cause  can  be  neither  in- 
jury nor  disease. 


378 


COSGEMTAL  DISLOCATION  OF  THE  HIP. 


Hereditary  influence  can  be  established  in  a  few  instances.  The 
writer  has  examined  three  female  children  in  a  family  of  nine,  in  each 
of  whom  there  was  dislocation  of  the  left  hip,  the  order  being  the  third, 
eighth  and  ninth  child.  Also  twins  in  another  family,  one  having 
single  and  the  other  double  dislocation.  And  in  two  instances,  con- 
genital displacement  was  present  in  the  mothers  of  patients. 

Of  the  various  theories  that  have  been  advanced  to  account  for  the 

condition,    the    most    reasonable 
Fig.  257.  seems    to    be  defective  develop- 

ment. This  defective  develop- 
ment may  aifect  the  entire  aceta- 
bulum or  it  may  involve  only  its 
posterior  margin,  or  the  cause  of 
the  displacement  may  be  an  ab- 
normal laxity  of  the  capsule  that 
predisposes  to  displacement  when 
the  thighs  are  flexed  and  ad- 
ducted. 

Heusner,^  from  an  examination 
of  26  foetuses  concluded  that  the 
greater  liability  of  females  to  the 
dislocation  is  explained  by  the 
disproportionate  laxity  of  the  cap- 
sule as  compared  with  males. 

It  is  probable  that  the  disloca- 
tion, in  some  cases  at  least,  is  at 
birth  a  subluxation  only,  that  be- 
comes complete  through  muscu- 
lar action  and  the  use  of  the  limb 
in  standing  and  walking. 

Symptoms.  —  The    displace- 
ment does  not  as  a  rule  attract 
attention  until  the  child  begins  to 
walk  ;  although  in  some  cases  the 
mother  may  have  noticed  a  pe- 
culiar   breadth    of  pelvis,  or    a 
"  lump "    on    the    buttock,  or    a 
"  snapping  "  about  the  hip  joint, 
or  a  peculiar  attitude  of  the  limb 
before  this  time. 
UxiLATERAL  DISLOCATION. — If  the  displacement  is  of  one  side,  a 
limp  is  immediately  apparent,  which  becomes  more  noticeable  as  the 
child  grows  older.     The  limp  is  peculiar  and  its  character  is  explained 
by  its  cause  ;  for  the  leg  is  not  only  shorter  than  its  fellow,  but  owing 
to  the  elasticity  of  the  capsule,  it  becomes  still  shorter  when  the  weight 
falls  upon  it,  so  that  in  walking  there  is  a  peculiar  lunge  of  the  body 
toward  the  short  leg,  that  has  been  likened  to  the  motion  in  walking 
'Zeits.  fiirOrth.  Chir.,  Bd.  V.,  H.  2,  8. 


Congenital  dislocation  of  both  hips,  illustrat- 
ing the  separation  of  the  thighs,  the  abnormal 
breadth  of  the  pelvic  region,  and  the  prominent 
trochanters. 


SYMPTOMS. 


379 


down  stairs.  The  head  of  the  bone  is  displaced  upward  and  back- 
ward, iand  in  compensation  the  pelvis  is  tilted  toward  the  short  leg  and 
its  inclination  is  increased  ;  it  is  thus  twisted  downward  and  forward 
so  that  the  anterior  superior  spine  lies  at  a  lower  level,  and  in  advance 
of  that  of  the  opposite  side.     (Figs.  255,  256.) 

At  an  early  age  the  shortening  of  the  leg,  due  to  the  elevation  of 
the  trochanter,  is  from  one-half  to  three-quarters  of  an  inch.  In  ado- 
lescence, the  elevation 

is  from  one  and   one-  Fig.  258. 

half  to  two  inches,  and 
in  adult  life  it  may  be 
considerably  more. 

The  effect  of  the 
displacement  is  also 
shown  by  a  flattening 
of  the  buttock,  and 
usually  the  elevated 
and  prominent  trochan- 
ter may  be  seen  as  an 
abnormal  lateral  pro- 
jection, on  a  level  with 
the  anterior  superior 
spine  which  is,  as  has 
been  stated,  somewhat 
tilted  downward. 

In  childhood,  mo- 
tion in  the  false  joint  is 
more  free  than  normal, 
and  the  abnormal  mo- 
bility can  be  demon- 
strated by  alternate 
traction  and  upward 
pressure  on  the  limb, 
but  as  the  femur  be- 
comes larger  and  the 
upward  displacement 
increases,  the  mobility 
is  restricted ;  the  range 
of  abduction  is  much 
diminished,  and  not  in- 
frequently the  limb  be- 
comes permanently  ad- 
ducted  and  flexed,  thus  adding  the  apparent  shortening  of  adduction 
to  that  caused  by  the  dislocation.      (Fig.  259.) 

Bilateral  Dislocation.  —  When  the  location  is  bilateral  the 
shortening  is,  as  a  rule,  equal  or  nearly  so,  and  as  both  femora  are 
displaced  backward  the  pelvis  is  tilted  forward  ;  thus  in  compensation 
"  the  hollow "  of  the  back  is  increased,  the  abdomen  protrudes,  the 


Bilateral  congeuital  dislocation  of  the  hip,  showing  the  exag- 
gerated lordosis. 


380  CONGENITAL  DISLOCATION  OF  THE  HIP. 

buttocks  are  flattened,  the  pelvis  appears  to  be  abnormally  wide  and 
the  thighs  are  separated  by  a  considerable  interval.  (Figs.  257,  258.) 
The  limp  characteristic  of  the  single  displacement  is  replaced  by  an 
exaggerated  waddle,  a  ''sailor  gait." 

General  Symptoms. — In  early  childhood  there  are  no  especial 
symptoms  other  than  the  limp  or  the  waddle  but  as  the  child  becomes 
more  active  it  usually  complains  of  discomfort  after  exertion.  It  is 
easily  fatigued  and  at  times  it  may  suffer  actual  pain.  These  symp- 
toms are  of  course  more  marked  in  the  double  than  in  the  single  dis- 
placement, because  in  the  latter  case  the  normal  leg  is  capable  of  bear- 
ing more  than  its  share  of  the  strain.  The  symptoms  often  increase 
during  adolescence  but  they  may  become  less  troublesome  in  adult  life, 
when  the  head  of  the  bone  may  have  found  a  permanent  resting  place 
on  the  pelvis  ;  a  security  assured,  however,  by  a  corresponding  limita- 
tion of  the  range  of  motion.  But  the  shortening  and  the  secondary 
effects  of  the  displacement  of  course  remain,  so  that  the  individual 

Fig.  259. 


.„-«»^ 


Congenital  dislocation  in  an  adolescent,  illustrating  ttie  flexion-contraction  in  a  well-marked  case. 

is,  as  compared  with  the  normal  standard,  more  or  less  disabled  and 
deformed. 

The  great  majority  of  the  patients  are  females  and  because  of  the 
less  laborious  occupations  and  the  distinctive  dress,  the  disability  and 
its  effects  are  less  serious  than  if  the  displacement  were  more  equally 
divided  between  the  sexes. 

Anterior  Dislocation. — The  symptoms  of  the  anterior  disloca- 
tion in  which  the  head  of  the  bone  lies  beneath  the  anterior  superior 
spine,  are  much  less  marked  because  the  relation  of  the  pelvis  to  the 
femur  is  nearly  normal,  so  that  secondary  deformity  is  slight.  The 
shortening  is  less  and  the  resistance  of  the  tissues  attached  to  the  an- 
terior superior  spine  is  sufficient  to  assure  a  more  secure  support  than 
in  the  ordinary  form. 

Diagnosis. — The  diagnosis  offers  no  difficulty.  The  history  of  the 
limp  or  waddle  noticed  when  the  child  began  to  walk  and  yet  unac- 
companied by  pain  or  preceded  by  injury  or  disease,  is  in  itself  suffi- 


BIAONOSIS.  381 

ciently  distinctive.  If  the  displacement  is  of  one  side,  measurement 
demonstrates  the  shortening  as  compared  with  the  other  limb,  a  short- 
ening that  is  explained  by  the  prominence,  and  the  elevation  of  the 
trochanter  above  Nekton's  line.  Traction  and  upward  pressure  on  the 
leg  will  demonstrate  the  abnormal  mobility  of  the  displaced  head  ;  and 
finally  if  the  thigh  be  flexed  and  adducted  to  its  extreme  limit,  the 
neck  and  head  of  the  femur  can  be  easily  distinguished  moving  under 
the  gluteal  muscles  when  the  leg  is  rotated.  Thus  it  may  be  differen- 
tiated from  depression  of  the  neck  of  the  femur  (coxa  vara),  in  which, 
althouo-h  the  trochanter  is  elevated,  the  neck  and  head  of  the  bone  can- 

Fig.  260. 


Bilateral  congenital  dislocation  of  the  hip. 

not  be  felt,  and  in  which  the  abnormal  mobility,  characteristic  of  the 
dislocation,  is  absent.  Again,  coxa  vara  is  almost  never  a  congenital 
affection,  therefore  the  history  itself  would  practically  exclude  it. 

Upward  displacement  of  the  femur  not  infrequently  follows  infec- 
tious EPIPHYSITIS  of  infancy  or  early  childhood.  In  such  cases  a  part 
of  the  upper  extremity  of  the  bone  is  usually  destroyed  so  that  the  head 
cannot  be  distinguished  on  palpation.  Although  the  other  physical  signs 
are  similar  to  those  of  the  congenital  displacement,  the  scars  about  the 
joint  show  the  evidence  of  former  disease,  and  the  history  is  almost 
always  available  for  diagnosis,  so  that  as  a  rule,  such  disabilities,  as 


382 


CONGENITAL  DISLOCATION  OF  THE  HIP. 


Fig.  261. 


well  as  traumatic  dislocations  or  other  results  of  injury  or  disease,  are 

readily  excluded.     (Fig.  217.) 

The  double  congenital  dislocation  presents  the  same  local  signs  as 

the  single  form ;   it  is  even  more  easily  recognized  by  the  peculiar 

appearance  and  distinctive  gait  of  the  patient. 

The  waddling  gait  may  be  simulated  by  that  of  extreme  bow  legs, 

but  the  hip  joints  are,  in  this  deformity,  normal  in  appearance  and 

function.  The  waddle  of  lumbae 
Pott's  disease  is  also  somewhat  simi- 
lar, but  this  is  an  acquired  painful  dis- 
ease of  the  spine,  in  which  the  hip  joints 
are  normal  in  appearance  and  usually 
so  in  function. 

PSEUDO-HYPERTROPHIC   PARALYSIS 

may  be  mentioned  as  causing  a  some- 
what similar  gait  and  attitude,  but  here 
the  resemblance  ceases. 

As  has  been  stated,  the  diagnosis  of 
congenital  dislocation  can  be  easily  made 
by  physical  examination  ;  the  only  real 
difficulty  is  experienced  in  early  infancy 
when  the  dislocation  may  be  incomplete, 
but  opportunity  for  such  early  diagnosis 
is  rarely  offered. 

In  doubtful  cases  a  Roentgen  picture 
will  demonstrate  the  character  of  the 
disability.     (Fig.  260.) 

Treatment. — Dupuytren  in  1829, 
after  a  careful  study  of  the  anatomy  of 
the  deformity,  made  the  statement  that 
it  was  not  only  incurable  but  that  pal- 
liation of  its  effects  even  was  hardly 
attainable;  and  for  sixty  years  the  state- 
ment remained  practically  undisputed. 
The  term  dislocation  naturally  sug- 
gests that  cure  can  only  be  attained  by 
replacement  of  the  displaced  bone  in  its 
proper  place,  and  in  1890  Hoffa  of 
Wlirzburg  first  performed  this  operation 
with  success,  by  opening  the  joint  from 
behind  and  enlarging  the  rudimentary  acetabulum  to  a  size  sufficient 
to  contain  the  head  of  the  bone.  Since  this  time  the  details  of  the 
operation  have  been  modified,  particularly  by  Lorenz  of  Vienna,*  who 
has  written  the  most  complete  works  on  the  subject. 

The  radical  cure  of  the  dislocation  can  be  accomplished  by  several 
procedures  : 

'  Patliologie  nnd  Tlieray)ie  der  Angebornen  Hiift  Verrenkung.    Wien,  1895.    Ueber 
heilung  der  Angebornen  Jliiftgelenk  Verrenkung.      Leipzig  u.  Wein,  1900. 


Bilateral  dislocation  in  adolescence. 
This  patient  was  practically  disabled 
by  pain  and  weakness. 


TREATMENT.  383 

1.  The  open  operation  with  direct  enlargement  of  the  rudimentary 
acetab^ulum. 

2.  Forcible  replacement  and  gradual  reformation  of  the  joint  by 
functional  use. 

3.  The  intermediate  operation. 

The  Open  Operation. — As  a  preliminary  treatment  the  head  of  the 
bone  must  be  drawn  down  to  a  point  corresponding  to  its  normal  posi- 
tion, so  that  the  trochanter  is  on  the  level  of  Nekton's  line  or  even 
below  it.  In  the  older  subjects,  traction  in  bed  by  means  of  adhesive 
plasters  and  the  weight  and  pulley,  as  described  in  the  treatment  of 
hip  disease  may  be  employed  for  this  purpose  with  advantage.  (See 
page  269.)  From  10  to  40  pounds  of  weight  may  be  used  according 
to  the  age  of  the  patient  and  the  resistance  of  the  tissues.  In  using 
this  strong  traction,  excoriations  must  be  guarded  against  by  constant 
supervision  and  readjustment  of  the  perineal  bands,  and  by  lessening 
the  weight  from  time  to  time  when  it  causes  discomfort.  In  younger 
subjects  the  tissues  may  be  sufficiently  stretched  by  manual  force  at 
the  time  of  operation. 

A  folded  sheet  is  passed  beneath  the  perineum,  the  two  ends  of 
which  are  held  by  an  assistant  at  the  head  of  the  table,  and  by  means 
of  intermittent  and  continuous  manual  traction  the  resistance  of  the 
contracted  parts  is  overcome.  The  traction  machine  of  Lorenz  may  be 
used  for  the  same  purpose,  but,  as  a  rule,  the  preliminary  extension  in 
-bed  is  to  be  preferred  to  the  use  of  extreme  force  at  the  time  of  opera- 
tion. When  the  tissues  are  sufficiently  relaxed  to  allow  the  trochanter 
to  be  drawn  down  to  its  normal  position,  the  joint  is  exposed  by  a  lat- 
eral incision  about  three  inches  in  length,  extending  downward  from  a 
point  about  three-quarters  of  an  inch  to  the  outer  side  of  the  anterior 
superior  spine  of  the  ilium,  the  fascia  is  divided  and  the  line  of  junction 
between  the  tensor  vaginae  femoris  and  the  gluteus  medius  muscles  is 
found.  These  muscles  are  then  separated  and  are  drawn  to  either  side 
by  retractors,  thus  exposing  the  capsule  of  the  joint.  The  ilio-psoas 
muscle,  which  often  covers  its  anterior  surface,  is  separated  from  it  and 
the  capsule  is  opened  by  an  incision  parallel  to  the  neck  of  the  bone. 
The  finger  is  then  passed  through  the  opening,  down  upon  the  rudi- 
mentary acetabulum.  A  strong  cervix  dilator  is  then  inserted  and  the 
contracted  capsule  is  thoroughly  stretched.  If  the  ligamentum  teres  is 
present,  it  is  removed ;  a  large  sharp  spoon  is  then  introduced  by  the 
side  of  the  finger  and  the  acetabulum  is  enlarged  to  its  normal  size  by 
removing  from  its  interior  the  fibrous  tissue,  fat  and  thickened  carti- 
lage. If  the  acetabulum  appears  to  be  of  sufficient  size,  as  is  not  in- 
frequent in  young  subjects,  this  procedure  may  be  omitted,  but  in  such 
an  event  the  danger  of  redisplacement  is  greater  and  the  limb  must  be 
fixed  in  an  attitude  of  flexion  and  abduction,  as  described  in  the  func- 
tional weighting  method.     (See  the  intermediate  operation.) 

If  the  head  of  the  bone  is  extremely  irregular  it  may  be  remodeled, 
but  this  is  rarely  necessary.  If  there  is  marked  anterior  rotation  of 
the  neck  upon  the  shaft,  the  head  should  be  replaced  in  the  acetabu- 


384 


CONGENITAL  DISLOCATION  OF  THE  HIP. 


lum,  the  leg  being  rotated  inward  to  a  sufficient  degree  to  prevent  re- 
displacement.  Later,  by  means  of  a  simple  linear  osteotomy  below  the 
trochanter  minor,  the  shaft  may  be  rotated  outward  and  the  normal 
relation  of  the  parts  restored.  In  six  instances  I  have  found  this 
secondary  operation  to  be  necessary.     (See  osteotomy.) 

After  the  head  has  been  replaced  the  wound  may  be  closed,  but  if 
the  acetabulum  has  been  excavated  a  small  opening  should  be  left  for 
drainage  as  the  serous  discharge  is  usually  considerable  in  amount.^  A 
plaster  of  Paris  spica  bandage  is  then  applied,  the  leg  being  fully  ex- 
tended, somewhat  abducted,  and  rotated  as  a  rule  slightly  inward,  so 
that  the  head  of  the  bone  may  be  completely  contained  within  the  new 

acetabulum.     The  first  band- 
FiG.  262.  age  usually  remains  in  position 

for  about  eight  weeks;  it  is 
then  replaced  by  one  which 
reaches  to  the  knee  only,  and 
the  patient  is  encouraged  to 
bear  the  weight  on  the  limb. 
At  the  end  of  another  month 
or  longer,  when  it  may  be 
supposed  that  repair  is  com- 
plete and  when  the  joint  is  no 
longer  sensitive  to  direct  man- 
ipulation, the  spica  is  removed. 
If  possible  regular  massage 
and  methodical  exercises  with 
the  aim  of  stimulating  and 
strengthening  the  disused  and 
misplaced  muscles,  should  be 
begun  and  continued  for  a 
year,  or  longer  if  necessary. 

After  the  open  operation 
the  range  of  motion  is  at  first 
much  limited  and  forced  man- 
ipulation causes  pain.  There 
is  also  in  many  instances  a 
tendency  toward  flexion  and 
adduction.  This  is  due  in  part  to  the  original  traumatism  of  the  opera- 
tion, in  part  to  the  weakness  of  the  abductor  and  extensor  muscles, 
and  in  some  instances  to  the  depression  of  the  neck  of  the  femur  that 
may  be  present. 

This  tendency  toward  deformity  must  be  resisted  by  massage  and 
manipulation  and  by  the  use  of  apparatus  if  necessary.  A  useful  form 
of  appliance  for  the  purpose  of  holding  the  leg  in  the  proper  attitude, 
is  a  simple  jointed  leg  brace  attached  to  the  shoe  and  to  a  pelvic  band. 
(Fig.  263.)  If  the  contraction  is  resistant  forcible  manipulation  under 
anaesthesia  may  be  required. 

1  Hoffa  does  not  close  the  wound,  but  packs  it  lightly  with  gauze. 


Scoops  used  in  the  treatineut  of  congeuital  dislocation, 
also  the  subcutaneous  osteotome. 


TREATMENT. 


385 


After  the  operation  the  legs  may  be  equal  in  length,  but  there  is  as 
a  rnld  a  shortening  of  about  a  half  inch  caused  by  the  excavation  of 
the  acetabulum  and  by  the  depression  of  the  neck  of  the  bone.  A 
limp  persists  for  a  year  at  least  and  usually  longer,  the  successful 
functional  result  being  dependent  upon  the  age  of  the  patient  and  upon 
the  care  that  has  been  exercised  in  the  after-treatment.  As  a  rule 
traces  of  the  former  disability  will  remain  in  most  instances  throughout 


Fig.  263. 


Fig.  264. 


Fig.  265. 


A  successful  result  after 
the  open  operation.  Shows 
a  useful  form  of  brace  to  be 
used  in  the  after-treatment. 


Eight  months  after  operation  by 
the  open  method. 


Bilateral  dislocation 
six  mouths  after  rejilace- 
ment  by  the  open  method. 
Illustrating  the  change  in 
the  contour  of  the  trunk. 


life  because  of  the  abnormalities  of  the  head  and  neck  of  the  bone  or 
elsewhere,  but  in  a  large  proportion  of  suitable  cases,  practical  cure 
may  be  obtained,  and  in  all  the  progress  of  the  deformity  may  be 
checked  and  the  symptoms  relieved  because  the  head  of  the  bone  has 
been  provided  with  a  secure  resting  place  in  its  normal  position.  Re- 
lapse is  unusual  if  the  operation  has  been  properly  conducted,  unless 
the  neck  of  the  bone  is  displaced  forward  in  its  relation  to  the  shaft  so 

25 


380  CONGENITAL  DISLOCATION  OF  THE  HIP. 

that  it  may  be  impossible  to  retain  the  head  iu  the  acetabulum  unless 
the  foot  is  rotated  inward. 

The  danger  of  the  operation  is  slight,  and  the  deaths  with  but  few 
exceptions  have  been  due  to  infection.  Lorenz  and  Hoffa  lost  several 
of  their  earlier  patients  from  this  cause,  but  with  improved  technique 
the  danger  is  slight.^  The  bad  results  of  the  operation  may,  as  a  rule, 
be  accounted  for  by  its  improper  performance,  particularly  the  failure 
to  replace  the  femur  securely,  or  by  failure  to  insure  asepsis,  or  by  in- 
efficient supervision  and  after-treatment. 

It  is  perhaps  unnecessary  to  state  that  operations  of  this  character 
should  not  be  performed  unless  asepsis  can  be  assured,  unless  the  oper- 
ator is  familiar  with  the  anatomy  of  the  parts  and  unless  the  essential 
after-treatment  can  be  provided. 

The  prognosis  in  bilateral  displacement  is  much  less  hopeful  than  in 
the  single  displacement  for  the  evident  reason  that  the  original  dis- 
ability as  well  as  the  chances  of  operative  mishap  are  twice  as  great. 

Reduction  of  the  Dislocation  without  Open  Operation.  The  "  Func- 
tional Weighting  Method  of  Lorenz." — The  Lorenz  treatment  is  based 
upon  the  theory  that  if  parts  about  the  joint  may  be  sufficiently 
stretched  to  allow  the  head  of  the  bone  to  be  brought  into  direct  con- 
tact with  the  rudimentary  acetabulum,  and  if  it  can  be  held  in  this 
position,  the  weight  of  the  body,  in  walking,  constantly  forcing  the 
bone  against  the  substance  that  partly  fills  it,  will  gradually  enlarge  it 
to  its  normal  capacity;  thus  it  is  called  the  "functional  weighting" 
method,  and  this  is  its  essential  and  vital  distinction  from  the  forcible 
correction  of  Paci,  with  which  it  is  often  confounded. 

The  steps  of  the  operation  are  :  1.  Elongation  of  the  limb. — The 
trochanter  must  be  brought  down  to  the  level  of  Nekton's  line  or  lower. 
This  may  be  accomplished  by  preliminary  traction  in  bed  with  heavy 
weights,  or  by  manual  force  at  the  time  of  operation,  the  latter  means 
being  efficient  in  young  subjects.  The  child  having  been  anaesthetized, 
a  folded  sheet  is  passed  between  the  legs  and  the  two  ends  are  held 
above  the  shoulder  of  the  side  to  be  operated  upon,  or  the  assistant 
may  clasp  his  hands  about  the  perineum  and  thus  fix  the  pelvis.  One 
then  seizes  the  thigh  and  begins  a  series  of  alternate  stretchings  and 
relaxations,  using  gradually  increasing  force  for  from  ten  to  twenty 
minutes,  or  until  the  resistance  of  the  tissues  is  entirely  overcome.  The 
leg  is  then  as  long  or  longer  than  its  fellow  and  lies  limp  in  an  attitude 
of  abduction. 

For  this  preliminary  extension  Lorenz  uses  a  powerful  machine  at- 
tached to  the  leg  by  means  of  a  band  about  the  ankle,  but  I  am  inclined 
to  think  that  the  manual  method  is  to  be  preferred  if  one  does  not  ob- 
ject to  the  labor  that  it  involves. 

2.  Reposition. — One  now  attempts  to  force  the  head  of  the  femur 

1  Hoffa  has  performed  the  operation  248  times  with  10  deaths — 8  due  to  the  opera- 
tion, the  last  132  operations  without  a  death.  Lorenz  in  260  operations  lost  4  patients 
from  septicEemia. — Report  of  the  Thirteenth  International  Congress,  Paris,  August, 
1900. 


THE  LORENZ  OPERATION. 


387 


over  the  ridge  that  represents  the  posterior  margin  of  the  acetabulum 
and  ihrough  the  opening  in  the  contracted  capsule. 

The  thigh  is  flexed  to  about  ninety  degrees  in  order  to  relax  the  cap- 
sule ;  it  is  then  gradually  and  forcibly  abducted  under  traction  to 
the  limit  of  the  range,  or  slightly  beyond  even,  so  that  the  head 
and  neck  of  the  bone  may  lie  in  the  same  plane  with  the  side  of  the 
pelvis  ;  the  thigh  is  then  rotated  slightly  inward  so  that  the  head  of 
the  bone  may  point  toward  the  opening  in  the  capsule,  and  while  trac- 
tion upon  the  thigh  is  continued  with  one  hand  the  other  exerts  pres- 
sure upon  the  trochanter  and  head  of  the  displaced  bone,  Avhich  is  then 
lifted  and  drawn  over  the  obstacle  formed  by  the  rim  of  the  acetabulum. 
If  this  is  successfully  accomplished  one  hears  and  feels  a  distinct  sound 
and  shock,  and  the  leg  remains  fixed  in  an  attitude  of  flexion  and  ab- 
duction. From  this  semi- 
replacement  the  bone  is  at  Fig.  266. 
once  displaced  when  the  leg 
is  adducted  or  extended. 

3.  Acetabulum  For- 
MATiox.  —  One  now  at- 
tempts to  enlarge  the  open- 
ing of  the  acetabular  part 
of  the  capsule.  While  the 
head  of  the  bone  is  forced 
against  or  through  the  open- 
ing, the  thigh  is  forcibly 
rotated  outward  again  and 
again,  and  extended  to  its 
full  limit,  in  order  that  the 
anterior  wall  of  the  capsule, 
which  is  drawn  tightly 
across  the  depression,  may 
be  distended  and  the  capac- 
ity of  the  new  articulation 
increased.  Finally,  the  pa- 
tient is  turned  upon  the  side 
and  direct  pressure  is  ex- 
erted on  the  trochanter 
while  the  limb  is  alternately 
flexed  and  extended. 

When  the  manipulation  is 
completed,  the  leg  is  fixed 
in  the  attitude  of  extreme 
abduction,  moderate  flexion  and  inward  rotation,  by  a  firm  plaster  spica 
bandage  extending  to  the  knee,  or  preferably,  slightly  below  it,  the 
leg  being  flexed  somewhat  on  the  thigh.  This  longer  bandage  insures 
better  fixation,  and  prevents  the  tendency  to  outward  rotation,  although 
it  interferes  somewhat  with  locomotion. 

At  the  time  of  operation  one  is  able  to  make  a  fair  prediction  as  to 


Unilateral  dislocation,  showing  the  attitude  in  the  early 
stage  of  the  Lorenz  treatment. 


388 


CONGENITAL  DISLOCATION  OF  THE  HIP. 


its  outcome  from  the  character  of  the  reposition  and  its  stability.  In 
some  instances  the  head  of  the  bone  seems  to  be  actually  replaced  in  a 
sufficient  cavity,  in  others,  it  appears  to  slip  from  side  to  side  with  but 
little  indication  of  fixation. 

In  properly  selected  cases  the  operation  is  free  from  danger,^  and  the 

Fig.  267. 


Unsuccessful  treatment  by  forcible  correction.    (Lorenz  operation.)    The  posterior  has  been  changed 
to  an  anterior  displacement.    Rear  view. 

'  Several  deaths  from  the  ansesthetic  employed  have  been  reported,  three  of  these 
by  Lorenz,  and  a  number  of  accidents  have  been  caused  by  violence  in  the  attempt  to 
reduce  the  displacement  in  adolescents. 


THE  LOBENZ  OPERATION.  389 

pain  and  discomfort  are  much  less  than  one  would  expect  after  the 
force 'that  has  been  employed.  Occasionally  there  is  some  discoloration 
about  the  adductor  region,  but  this  is  practically  the  only  noticeable 
evidence  of  the  manipulation. 

As  soon  as  possible  the  child  is  encouraged  to  stand  and  to  walk, 
the  awkwardness  caused  by  the  extreme  abduction  being  somewhat 
lessened  by  a  cork  sole,  an  inch  or  more  in  thickness,  on  the  other 
shoe. 

The  first  bandage  should  remain  in  place,  if  possible,  for  six  weeks 
or  longer.  When  it  is  removed,  one  examines  the  relation  of  the 
parts ;  if  the  reposition  has  been  unsuccessful  the  head  of  the  bone 
may  be  felt  beneath  the  anterior  superior  spine  ;  the  posterior  has 
been  transformed  simply  into  an  anterior  displacement.  In  such 
cases  the  operation  may  be  repeated,  but  in  my  own  experience  the 
secondary  operation  has  never  been  successful.  If  the  head  of  the  bone 
appears  to  be  in  its  proper  position,  the  bandage  is  again  applied.  At 
the  end  of  another  month  or  more,  and  with  each  successive  change 
thereafter,  the  extreme  attitude  of  abduction  may  be  somewhat  lessened, 
until,  at  the  end  of  eight  or  ten  months,  the  normal  attitude  of  the  limb 
is  restored.  The  plaster  bandage  is  then  removed,  but  it  is  well  to  re- 
place it  by  a  simple  jointed  brace  attached  to  the  shoe  and  to  a  pelvic 
band,  by  this  means  the  foot  may  be  rotated  slightly  inward  and  mod- 
erate pressure  may  be  exerted  on  the  trochanter.     (Fig.  263.) 

During  the  course  of  treatment  a  failure  in  reposition  usually  be- 
comes evident,  and  in  any  event  success  is  not  assured  until  after  all 
support  has  been  removed.  Roentgen  pictures  are,  of  course,  of  service 
in  showing  the  true  relation  of  the  parts,  if  they  are  available. 

As  this  operation  was  first  performed  in  1895,  sufficient  time  has 
not  elapsed  to  report  definitely  upon  final  results.  But  in  selected 
cases  I  am  inclined  to  believe  that  about  25  per  cent,  of  the  patients 
may  be  cured  by  this  means  alone.  The  treatment  of  bilateral  displace- 
ment by  this  method  is  less  satisfactory.  As  a  rule  it  is  advisable  to 
operate  upon  but  one  hip  at  a  time. 

It  should  be  stated  that  a  method  of  forcible  correction,  preceding  that 
of  Lorenz,  was  introduced  by  Paci  of  Pisa  in  1887.^  Another,  and 
somewhat  similar,  system  is  practiced  by  Schede.^  As  these  methods 
are  less  definite  and  satisfactory  than  that  of  Lorenz,  a  detailed  account 
of  them  is  unnecessary. 

If  the  simple  operation  is  unsuccessful,  it  must  be  supplemented  by 
the  open  method.  This  will  be  necessary  in  the  larger  proportion  of 
cases,  particularly  in  older  subjects,  but  the  second  operation  will  be 
much  simpler  and  more  easily  performed  because  the  preliminary  treat- 
ment will  have  improved  the  relation  of  the  parts. 

The  great  advantage  of  this  treatment  is,  that  it  can  be  applied  as 
soon  as  the  diagnosis  is  made,  for  being  free  from  danger  and  not  ne- 
cessitating a  cutting  operation  or  confinement  to  a  hospital,  the  consent 

1  Archiv  di  Ortop.,  1892,  p.  420. 
zArchiv  f.  Klin.  Chir.,  Bd.  43,  1892. 


390 


CONGENITAL  DISLOCATION  OF  THE  HIP. 


of  parents  is  readily  obtained  ;  this  is  certainly  not  true  of  the  older 
method.  There  is  also  another  advantage,  in  that  the  muscles  become 
accommodated  to  the  changed  relations  of  the  parts  while  the  leg  is 
fixed  by  the  plaster  bandage,  so  that  the  long-continued  supervision 
and  gymnastic  training,  that  are  essential  after  the  open  operation,  may 
be  dispensed  with.  Even  if  the 
operation    has    merely   resulted    in  Fig.  269. 

changing  a  posterior  into  an  anterior 
displacement,  it   may  be  classed  as 

Fig.  268. 


HlW^ 


^ 


Unilateral  disloeatiou.  Two 
years  after  operation  by  the  Lorenz 
method.    A  complete  cure. 


Unilateral  dislocation.    Eighteen  months  after 
operation  by  the  Lorenz  method.   A  complete  cure. 


a  half  cure,  since  the  deformity  of  the  spine  is  checked  and  the  short- 
ening of  the  leg  is  much  reduced. 


The  Intermediate  Operation. 

The  uncertainty  of  the  forcible  operation  on  the  one  hand  and  the 
limitation  of  motion  and  distortion  that  may  follow  the  enlargement  of 
the  acetabulum  on  the  other,  suggest  the  desirability  of  an  intermediate 


REVIEW  OF  THE  TREATMENT. 


391 


operation  which  may  combine  in  some  degree  the  advantages  of  each. 
Such  is  the  operation  of  simple  replacement  by  means  of  open  incision. 
The  operation  is  identical  with  that  described  except  that  the  acetab- 
ulum is  not  enlarged,  and  that  the  further  details  of  the  non-bloody 
operation  are  followed.     The  limb  is  fixed  in  a  position  of  abduction 
and  inward  rotation,  although   not  in  as  extreme 
Fig.  270.  degree  as  when  the  open  incision 

has  not  been  employed.  Fig-  271. 


Secondary  Osteotomy. 


^ 


\ 


If  on  examination  during  the 

open  operation  the  neck  of  the 

femur  is  found  to  be  anteverted 

to  a  marked  degree,  its  relation 

to  the    shaft    must    be    restored, 

otherwise  the   anterior  displace- 
ment is  inevitable  when  the  limb 

is  replaced  in  the  proper  attitude. 

To  accomplish  this  the  shaft  of 

the  femur  may  be  divided  by  the 

subcutaneous  osteotome  just  below 

the    trochanter    minor,    a    long 

slender    drill    is    then    inserted 

through    the  trochanter  into  the 

neck  of  the  femur.    This  controls 

the  upper  fragment  and  indicates 

its  position.     The  shaft  is  then 

rotated  outward  to  the  proper  de- 
gree and  a  plaster  spica  bandage 

is  applied,  through  which  the  drill 

projects.    In  a  few  days  it  may  be 

removed.      The    details    of    the 

after-treatment  do  not  differ  from 

those  of  the  ordinary  cases. 
Review  of  the  Treatment  of 

Congenital  Dislocation  of  the 
Hip. — The  prospect  of  success  in  treatment  stands  in  direct  relation  to 
the  age  of  the  patient,  since  the  extent  of  the  pathological  changes 
that  make  cure  difficult  or  impossible,  depends  in  some  degree,  as  in 
acquired  dislocations,  upon  the  duration  of  the  disability.  Conse- 
quently treatment  should  be  applied  as  soon  as  the  displacement  is 
discovered,  and,  as  has  been  stated,  there  is  little  excuse  for  not  mak- 
ing the  correct  diagnosis  as  soon  as  the  child  begins  to  walk.  The 
treatment  of  selection,  before  the  age  of  six  years,  is  the  functional 
weighting  method  of  Lorenz.  By  this  means  a  certain  proportion  of 
the  cases  may  be  cured,  and  in  all  instances  the  posterior  may  be 
changed  into  an  anterior  displacement,  which  makes  the  after-treat- 


W>^ 


boXi^ 


Unilateral  disloca- 
tion. After  operation 
by  the  Lorenz  method. 
A  complete  cure.  Com- 
pare with  Fig.  255. 


Unilateral  disloca- 
tion. Two  years  after 
operation.  Compare 
with  Fig.  256. 


392  COXA  VARA. 

raent  much  easier.  If  this  treatment  is  ineifective,  it  should  be  fol- 
lowed by  the  open  method.  In  the  younger  patients,  simple  incision 
and  forcible  stretching  of  the  capsule  may  be  sufficient,  if  the  acetab- 
ulum is  well  formed ;  if  not,  it  will  be  necessary  to  enlarge  it  to  the 
normal  size.  The  same  system  may  be  followed  in  older  children,  but 
the  simple  correction  is  much  less  likely  to  be  successful  although 
cures  have  been  reported  at  ages  far  beyond  this  limit.  As  a  rule  then, 
in  this  older  class  the  open  operation  may  be  performed  primarily,  the 
operation  being  preceded  if  possible  by  traction  in  bed,  so  that  all  con- 
tractions may  be  completely  overcome.  In  patients  beyond  the  age  of 
tfen  years  the  prognosis  is  very  doubtful,  although  the  treatment  may 
be  attempted  in  suitable  cases. 

All  other  methods  of  treatment,  by  long-continued  traction  in  bed, 
by  braces  for  support  or  pressure — by  tenotomy  and  scarification  of  the 
part — by  "  sclerogenous  injection  "  and  the  like,  have  been  practically 
abandoned. 

For  simple  palliation  a  corset  which  lessens  the  exaggerated  lordosis 
and  provides  pressure  over  the  trochanters  is  of  some  service  in  the 
double  dislocation.  Some  form  of  brace  attached  to  the  shoe  by  which 
the  weight  of  the  body  is  supported  on  a  perineal  strap  as  described  in 
the  treatment  of  the  convalescent  stage  of  hip  disease,  and  which  ex- 
erts pressure  on  the  trochanter  may  be  employed  in  the  single  form 
supplemented  by  exercises  and  by  massage.  By  such  means  the 
progress  of  the  deformity  may  be  checked  and  some  improvement  in 
the  position  and  stability  of  the  bone  may  be  assured,  although  increase 
of  the  deformity  may  be  expected  when  the  treatment  is  discontinued, 
A  "  high  shoe ''  to  equalize  the  length  of  the  limbs,  to  lessen  the  limp 
and  to  prevent  permanent  distortion  of  the  spine  is  indicated  also. 
Over-exertion  and  laborious  occupations  should  be  avoided.  This  is 
of  especial  importance  during  childhood  and  adolescence  when  the  ten- 
dency toward  an  increase  of  the  disability  is  most  apparent,^ 

Coxa  Vara. 

Synonyms, — Depression  or  incurvation  of  the  neck  of  the  femur. 
Bending  of  the  neck  of  the  femur. 

The  character  of  this  deformity  is  indicated  by  the  synonyms,  while 
the  term  coxa  vara  signifies  that  its  causes  and  effects  are  similar  to 
those  of  genu  valgum  and  varum,  the  more  common  distortions  of  the 
lower  extremities. 

Genu  valgum  and  varum  are  common  in  childhood,  but  rarely  de- 
velop in  adolescence.  Coxa  vara  is,  in  comparison,  not  only  an  infre- 
quent deformity,  but  it  is  peculiar  also  in  that  it  more  often  appears  in 
later  childhood  or  adolescence  than  at  the  earlier  period,  doubtless 
because  the  neck  of  the  femur  is,  at  the  age  when  rhachitic  distortions 
are  common,  very  short  and  is  relatively  stronger  than  the  shaft,  while 
in  adolescence  the  conditions  may  be  reversed. 

'  The  bibliography  of  the  subject  may  be  found  in  the  volumes  of  the  Zeits.  fiir 
Orth.  Chir. 


ETIOLOGY. 


393 


The  distortions  at  the  knee  are  self  evident,  but  the  neck  of  the 
femur  .is  concealed  from  view,  thus  the  diagnosis  of  coxa  vara  may  be 
somewhat  difficult ;  and  in  fact,  it  is  only  in  very  recent  years  that  its 
symptoms  have  been  recognized.  Fiorani  ^  first  described  the  deform- 
ity as  it  had  been  observed  by  him  in  children,  but  E.  Miiller  ^  first 
called  attention  to  the  aifection  as  one  of  the  deformities  of  adolescence, 
which,  until  that  time,  had  been  mistaken  for  hip  disease. 

Pathology. — The  term  coxa  vara  should  not  be  applied  to  depres- 
sion of  the  neck  of  the  femur  that  may  be  secondary  to  destructive 
disease  ;  for  example,  to  osteomyelitis,  arthritis  deformans  and  the 
like,  but  it  should  be  reserved  for 

cases  of   simple   local    deformity.  Fig.  272. 

In  most  instances  the  deformity 
affects  the  neck  as  a  whole,  in 
others  it  is  most  marked  at  the 
epiphyseal  junction.  A  number 
of  specimens  have  been  examined 
but  no  changes,  other  than  such  as 
might  be  caused  by  the  deformity 
itself,  have  been  found.  These 
are,  in  brief,  congestion  and  soften- 
ing of  the  bone,  and  evidences  of 
irritation  within  the  joint  during 
the  progressive  stage  of  the  defor- 
mity and  the  general  adaptive 
changes  in  all  the  components  of 
the  joint  that  always  accompany 
displacement  or  distortion. 

Etiology.  —  Some  writers  as- 
sume that  the  weakness  of  the 
neck  of  the  femur  that  induces 
the  deformity  is  the  result  of  local 
disease  such  as  so-called  local 
rickets,  or  local  osteomalacia. 
This  is  however  simply  a  conve- 
nient hypothesis.     Others  believe 

the  deformity  to  be  symptomatic  of  late  rickets ;  but  evidence  of  general 
rhachitis  is  almost  never  present  in  the  ordinary  type  of  cases. 

Coxa  vara  is  one  of  the  group  of  static  deformities  of  the  lower  ex- 
tremity caused  by  a  disproportion  between  the  strength  of  the  sup- 
porting structure  and  the  burden  that  is  put  upon  it.  The  support 
may  be  disproportionately  weak  because  of  inherited  delicacy  of  struc- 
ture, or  it  may  be  weakened  by  injury  or  by  disease,  or  over-burdened 
by  weight  or  strain. 

Mechanical  Predisposition  to  Deformity. — In  many  cases 
the  predisposition  to  deformity  is  the  result  of  a  lessened  angle  of 

'  Gazetta  degli  Ospitale,  Nos.  16-17,  1881. 

2Beitrao:e  zur  Klin.  Chir.,  1889,  Bd.  4. 

3  Humphrey,  Jour.  Anat.  Pliys.,  Vol.  XXIII.,  p.  236. 


Section  of  the  upper  extremity  of  a  normal 
femur  at  eight  years  of  age  ;  angle  formed  by  the 
neck  with  the  shaft  140  degrees.  In  the  normal 
subject  the  neck  of  the  femur  projects  sliglitly  for- 
ward (12  degrees),  and  upward  to  form  an  angle 
with  the  shaft  of  about  125  degrees.  In  childhood 
this  angle  is  usually  somewhat  greater,  and  in 
later  years  it  may  be  somewhat  less  than  125  de- 
grees ;  in  fact  a  variation  between  110  and  140  de- 
grees may  be  within  the  normal  limit. ^ 


394  COXA   VARA. 

the  femoral  neck.  This  slight  and  predisposing  depression  which  ap- 
pears to  be,  in  many  instances,  the  effect  of  early  rhachitis,  becomes 
exaggerated  to  deformity  during  later  childhood  or  adolescence.  The 
importance  of  this  mechanical  factor  in  the  etiology  was  demonstrated 
to  me  by  the  investigation  of  a  number  of  cases  of  simple  fracture  of 
the  neck  of  the  femur  in  childhood.  In  these  cases  the  neck  of  the 
femur  was,  by  the  original  injury,  somewhat  depressed,  and  although 
complete  functional  recovery  followed,  yet  in  a  number  of  the  cases, 
progressive  deformity,  attended  by  the  symptoms  of  typical  coxa  vara, 
resulted.  This  could  be  explained  only  on  the  theory  that  the  lessened 
angle,  subjecting  the  part  to  greater  strain,  was  the  predisposing  cause 
of  the  later  disability.  Other  factors  in  the  etiology  may  be  general 
weakness,  incident  to  rapid  growth,  direct  injury  or  the  strain  of  occu- 
pation.^ 

In  this  connection  it  may  be  stated  that  fracture  of  the  neck  of  the 
femur  in  childhood  may  cause  a  deformity  which  in  the  absence  of  a 
history  could  not  be  distinguished  from  the  ordinary  form  of  coxa  vara, 
of  which  in  fact,  it  is  the  traumatic  form.  (See  fracture  of  the  neck  of 
the  femur.) 

Statistics. 

The  deformity  is  far  more  often  unilateral  than  bilateral  and  more 
than  three-fourths  of  the  cases  are  in  males.  In  a  total  of  109  casea 
(collected  from  the  literature,  including  39  personal  observations,  83 
were  in  males  and  26  in  females ;  85  were  unilateral  and  24  were  bi- 
lateral. The  more  important  details  in  the  39  cases  that  have  come 
uader  my  observation,  are  presented  in  the  accompanying  table. 

The  points  of  especial  interest  may  be  summarized  as  follows  :  In 
about  one-third  of  the  cases  there  was  a  distinct  history  of  rhachitis 
in  infancy.  The  ages  at  which  the  symptoms  became  noticeable  ap- 
peared to  be  as  follows  : 

Adolescents,  12  to  17 20 

Later  childhood,  5  to  11 13 

Early  childhood,  less  than  5 6 

Unknown 1 

Total M 

29  of  the  patients  were  males,  10  were  females.  In  33  cases  the 
deformity  was  unilateral,  in  G  it  was  bilateral.  In  34  cases  the  neck 
of  the  femur  was  distorted  in  a  direction  backward  as  well  as  downward, 
in  2  directly  downward,  in  3  forward  and  downward.  In  each  case 
of  the  last  group  the  deformity  was  bilateral.     (See  table,  page  395.) 

Symptoms.  1.  Mechanical  Effects. — The  character  of  the 
symptoms  may  be  explained  by  a  description  of  the  distortion  and 
of  its  direct  effects  upon  the  function  of  the  joint.  When  the  neck  of 
the  femur  is  depressed,  for  example,  to  a  right  angle  with  the  shaft, 

'  One  case  of  congenital  coxa  vara  has  been  reported  by  Kredel  (Cent,  fiir  Chir. , 
N.  42,  1896).  Depression  of  the  neck  of  the  femur  in  congenital  dislocation  of  the 
hip  has  been  mentioned  in  the  section  on  that  affection. 


SYMPTOMS. 


395 


..    •! 

0  M 

0)   <D 

o 

1  ^ 

-i 

"Sa^ 

!■§ 

M 

ue.  ^^ 

Name. 

Date. 

1 

Duration. 

g-2§ 

^.s 

a 

w^  ®S 

M 

fa 

2 

a5 
60 

^  0 
3  bo 

«.9 

2  60 

c3  a 

t» 

JB 

< 

« 

< 

<1 

K 

1  Nelson 

Oct.  1896 

F. 

E. 

2>^ 

6  months 

Post. 

p 

Y 

Yes 

2  Van  Orden 

June  1896 

M. 

R. 

4 

1  year 

Post. 

% 

No 

3  Zeltermann 

Jan.  1898 

M. 

R. 

7 

6  months 

Post. 

/2 

y 

Yes 

4  Vitt 

Mar.  1897 

M. 

L. 

7 

6  months 

Post. 

1 

1 

Yes 

5  Tuit 

July  1899 

F. 

L. 

^y^ 

6  months 

Post. 

Yi 

% 

Yes 

6  Seeger 

Mar.  1897 

F. 

L. 

8 

2  years 

Post. 

1 

1 

No 

7  Rose 

Jan.  1888 

F. 

D. 

8 

3  years 

Post. 

_ 

— 

No 

8  Cohen 

June  1898 

M. 

R. 

8 

6  months 

Post. 

y-i 

y 

Yes 

9  Kebesky 

Aug.  1900 

M. 

L. 

8 

6  months 

Down'd 

^ 

y 

Yes 

10  Dengher 

July  1900 

M. 

R. 

8 

1  year 

Down'd 

y^ 

y^ 

Yes 

11  Hirsch 

Mar.  1897 

M. 

D. 

9 

2  years 

Ant. 

Yes 

12  Reardon 

Mar.  1898 

M. 

D. 

11 

6  years 

Ant. 

— 

— 

Yes 

13  Beckmyer 

Mar.  1895 

M. 

D. 

11 

8  years 

Post. 

— 

— 

Yes 

14  Brill 

Mar.  1894 

M. 

R. 

11 

1  year 

Post. 

1 

1 

No 

15  Greer 

Jan.  1896 

M. 

L. 

12 

8  years 

Post. 

1 

1 

Yes 

16  Thomas 

Mar.  1898 

F. 

D. 

12 

1  year 

Ant. 

R.  % 

?4 

Yes 

17  Abrams 

Mar.  1898 

F. 

R. 

13 

10  years 

Post. 

2 

? 

No 

18  Rutschmann 

July  1896 

M. 

R. 

13 

6  months 

Post. 

y-i 

No 

19  Fraad 

Nov.  1894 

M. 

R. 

13 

1  year 

Post. 

34 

y 

No 

20  Shandley 

Dec.  1898 

F. 

R. 

13 

1  year 

Post. 

i 

IK 

21  Skid  more 

Nov.  1899 

M. 

L. 

13 

3  years 

Post. 

K 

1^ 

22  Cords 

May  1900 

M. 

R. 

14 

3  months 

Post. 

y^ 

^y 

Yes 

23  Cunningham 

May  1897 

F. 

L. 

14 

1  year 

Post. 

Yi 

^y 

No 

24  Herbert 

Apr.  1897 

M. 

R. 

14 

6  months 

Post. 

1 

1 

No 

25  Bruning 

Oct.  1897 

M. 

R. 

15 

2  months 

Post. 

y-i 

1 

No 

26  Betz! 

June  1892 

M. 

R. 

15 

1  year 

Post. 

% 

3 

No 

27  Lawson 

Oct.  1897 

M. 

R. 

15 

]  year 

Post. 

9% 

'^ 

No 

28  Rose 

Jan.  1896 

M. 

L. 

15 

14  months 

Post. 

% 

No 

29  Allen 

Apr.  1897 

M. 

L. 

16 

1  month 

Post. 

1 

IK 

No 

30  Puckhaber 

June  1893 

M. 

D. 

16 

8  months 

Post. 

— 

Yes 

31  Gieger 

May  1900 

M. 

L. 

16 

6  months 

Post. 

y 

iM 

No 

32  Schade 

July  1898 

M. 

L. 

16 

18  months 

Post. 

1 

1 

33  Morris 

Jan.  1900 

M. 

R. 

17 

6  months 

Post. 

34 

S 

No 

34  Jocker 

Dec.  1899 

M. 

L. 

17 

1  month 

Post. 

^ 

No 

35  Beck 

July  1898 

F. 

R. 

17 

1  year 

Post. 

ll 

1% 

No 

36  Zimmermann 

Oct.  1896 

M. 

R. 

17 

13  months 

Post. 

1 

2^ 

No 

37  Fessner 

Mar.  1894 

M. 

L. 

17 

6  months 

Post. 

% 

No 

38  Enderlich 

Jan.  1897 

F. 

R. 

22 

1  year 

Post. 

% 

1 

No 

39  Adult 

Mar.  1896 

M. 

R. 

36 

Post. 

1 

IK 

No 

the  trochanter  is  elevated  to  a  corresponding  degree  above  N§la ton's 
line  and  forms  a  noticeable  projection  as  contrasted  with  the  normal 
contour  (Fig.  276),  a  projection  that  becomes  more  marked  when  the 
thigh  is  flexed  and  adducted.  (Fig.  275.)  In  most  instances  the 
neck  is  displaced  backward  as  well  as  downward,  following  the  line  of 
least  resistance,  and  as  the  head  of  the  bone  remains  in  the  acetabulum 
the  trochanter  is  thrown  forward  and  the  limb  is  rotated  outward. 
The  ability  to  abduct  the  thigh  is  dependent  upon  the  length  and  upon 
the  upward  inclination  of  the  femoral  neck  (Fig.  154);  when,  there- 
fore, this  inclination  is  diminished  the  range  of  abduction  is  lessened, 
in  part  by  the  greater  tension  that  is  exerted  upon  the  lower  portion 
of  the  capsule,  in  part  by  the  direct  contact  (Fig.  273)  of  the  rim  of 
the  acetabulum  with  the  neck  and  trochanter  and  in  part  by  the 
adaptive  contractions  that  always  accompany  displacements  of  this  char- 
acter. It  is  evident  also  that  the  distortion  of  the  neck  backward 
and  downward  changes  the  relation  of  the  acetabulum  to  the  head  of 
the  bone,  so  that  abduction  or  flexion  tends  to  displace  it  from  its 
socket.  Thus  the  range  of  abduction,  of  inward  rotation  and  of  flexion 
is  limited,  while  that  of  adduction,  outward  rotation  and  extension, 
may  be  increased. 


396 


COXA   VABA. 


There  is  actual  shortening  of  the  limb  dependent  upon  the  upward 
displacement  of  the  shaft  of  the  femur ;  this  is  not  often  more  than  an 
inch  in  the  ordinary  type  of  adolescent  deformity,  but  the  apparent 
shortening,  caused  by  the  adduction  and  the  accommodative  upward 
tilting  of  the  pelvis,  may  be  extreme,  from  two  to  three  inches  is  not 
uncommon,     (Fig.  276.) 

2.  Physical  Effects. — The  symptoms  of  coxa  vara  of  the  ordinary 
form,  are  :  Discomfort,  awkwardness,  limp,  shortening,  atrophy,  limita- 
tion of  motion,  deformity. 

Coxa  vara  is  a  more  disabling  deformity  than  genu  varum  or  val- 
gum and  its  attendant  symptoms  of  discomfort,  weakness  and  pain, 
are,  as  a  rule,  more  marked.     This  is  explained  by  the  fact  that  in 


Fig.  273. 


Skiagram  of  coxa  vara,  deformity  most  marked  at  the  epiphyseal  junction.  This  illustrates  the  me- 
chanical limitation  of  abduction  caused  by  the  deformity,  and  the  compensatory  tilting  of  the  pelvis. 
The  patient  is  shown  in  I<"ig.  276. 

coxa  vara,  the  head  of  the  bone  is  in  part  displaced  (Fig.  274)  from 
the  acetabulum,  while  in  the  deformities  at  the  knee  the  joint  surfaces 
remain  in  practically  normal  relation  to  one  another. 

The  symptoms  of  unilateral  coxa  vara  vary  with  the  degree  and  with 
the  duration  of  the  deformity.  ,  The  patient  usually  complains  of  sen- 
sations of  stiffness  and  weakness,  referred  to  the  thigh.  These  are 
more  noticeable  on  changing  from  a  position  of  rest  to  one  of  activity 
and  at  times,  particularly  after  over-exertion,  there  may  be  actual  pain. 
By  far  the  most  important  symptom  and  the  one  that  almost  always 
induces  the  patient  to  seek  treatment,  is  the  limp.  This  limp  accom- 
panied, as  it  usually  is,  by  outward  rotation  of  the  foot,  resembles  that 
caused  by  fracture  of  the  neck  of  the  femur.     On  physical  examina- 


OTHER    VARIETIES  OE  COXA   VARA. 


397 


tion  the  actual  shortening,  explained  by  the  elevated  and  prominent 
trochanter  and  the  peculiar  unequal  limitation  of  motion,  will  make  the 
diagnosis  clear.  In  some  instances  there  may  be  a  slight  degree  of  mus- 
cular spasm  and  there  is  usually  some  atrophy  of  the  muscles  of  the  thigh. 

Bilateral  Coxa  Vara. — If  the  deformity  is  bilateral  its  effect  upon  the 
gait  and  attitude  is  more  marked.  The  gait  is  extremely  awkward, 
resembling  somewhat  that  of  knock  knees,  for  the  limitation  of  abduc- 
tion forces  the  patient  to  sway  the  body  from  side  to  side  in  order  that 
the  legs  may  pass  one  another,  and  if  the  deformity  is  extreme  the  limbs 
may  be  crossed  over  one  another,  so  that  locomotion  may  be  difficult. 
Bilateral  coxa  vara  is  not 

infrequently    accompanied  Fio.  274. 

by  other  deformities,  as, 
for  example,  knock  knee  or 
flat  foot.     (Fig.  277.) 

Other  Varieties  of 
Coxa  Vara. — In  rare  in- 
stances the  neck  of  the  femur 
may  be  depressed  directly 
downward  or  even  down- 
ward and  forward.  In  the 
latter  instance  the  effect  of 
the  deformity  upon  the  func- 
tion of  the  joint  is  some- 
what different  from  that  of 
the  ordinary  type.  Abduc- 
tion is  limited  as  in  the 
common  form,  but  inward 
rotation  replaces  outward 
rotation  and  extension  is 
limited  in  place  of  flexion. 
This  type  of  deformity  is 
almost  always  bilateral.  It 
is  accompanied,  usually, 
by  slight  permanent  flex- 
ion of  the  thighs  ;  thus  the 

lumbar  lordosis  is  exaggerated,  whereas,  in  the  ordinary  form,  it  is 
usually  lessened. 

This  description  applies  to  the  ordinary  types  of  the  deformity 
as  it  is  seen  in  later  childhood  and  in  adolescence.  It  undoubtedly 
occurs  in  early  life,  but  it  is  masked  by  the  more  noticeable  dis- 
tortions of  other  parts,  and  as  an  isolated  deformity  that  demands 
treatment,  it  is  rare.  One  case  was  observed  by  the  writer  in  a 
rhachitic  child  two  and  one-half  years  of  age.  The  symptoms,  though 
slight,  were  typical,  and  the  diagnosis  was  confirmed  by  a  Roentgen 
picture.  In  other  cases  seen  in  later  childhood,  the  history  of  more  or 
less  discomfort  for  many  years,  seemed  to  indicate  that  the  deformity 
was  caused  directly  by  rhachitis. 


Cross  section  of  the  pelvis  and  the  deformed  femur.  A 
scheme  to  show  the  effect  of  the  deformity  in  limiting  ab- 
ductioa  of  the  limb.  The  dotted  outline  shows  the  normal 
relation. 


398 


COXA  VARA. 


In  the  majority  of  cases  the  symptoms  begin  insidiously  although 
in  many  instances  they  may  be  ascribed  to  injury  or  to  over-exertion. 
If  the  affection  begins  in  adolescence  and  is  untreated,  the  period  of 
discomfort  during  which  the  depression  of  the  neck  may  be  assumed 
to  be  progressive,  is  from  one  to  three  years  ;  but  if  the  deformity 
appears  at  an  early  age,  the  symptoms,  though  remittent  in  character, 
may  continue  indefinitely.    When  the  resistance  of  the  compressed  bone 


Fig.  275. 


Coxa  vara,  showing  prominent  trochanter. 


Fig.  276. 


%A^ 


Case  II.  Shows  the  tilting 
of  the  pelvis  and  the  apparent 
shortening  of  the  leg  in  unilat- 
eral coxa  vara.  Actual  sliort- 
ening%inch  ;  apparent  short- 
ening25^  inches.  See  skiagram 
(Fig.  273). 


becomes  sufficient  to  insure  stability,  the  discomfort  ceases  and  the  dis- 
ability becomes  less  marked,  as  Nature  accommodates  the  mechanism  to 
the  new  conditions. 

Diagnosis. — In  most  instances  diagnosis  may  be  easily  made,  and 
yet  coxa  vara  is  very  often  mistaken  for  hip  disease ;  in  fact  we  are 
indebted  to  this  mistake  for  most  of  the  specimens  of  the  deformity 
that  have  been  described.     The  essential  differences  between  the  two 


TREATMENT. 


399 


are  as  follows  :  In  tuberculous  disease  of  the  hip  the  motions  of  the 
joint  are  limited  in  every  direction  by  reflex  muscular  spasm,  and  as  a 
rule,  other  evidences  of  the  character  of  the  disease  are  apparent.  Coxa 
vara  is  a  simple  deformity ;  reflex  muscular  spasm  is  absent,  except 
during  exacerbations  due  to  injury  or  over-strain,  and  movement  is  not 
limited  in  all  directions,  but  only  in  abduction,  flexion  and  inward 
rotation  when  the  deformity  is  of  the  ordinary  type.  Actual  short- 
ening is  a  late  symptom  of  hip  disease,  while  it  is  present  from  the 
very  onset  of  coxa  vara.  It  is  a  shortening  explained  by  the  eleva- 
tion of  the  trochanter  above  Nelaton's  line,  while  such  elevation  in  hip 
disease  is  a  sign  of  de- 
struction, either  of  the  Fig.  277. 
head  of  the  bone  or  of  a 
part  of  the  acetabulum. 

The  deformity  might 
be  readily  mistaken  for 
congenital  dislocation  of 
the  hip,  particularly  of  the 
anterior  variety,  but  this 
would  be  excluded  by  the 
history,  since  coxa  vara  is 
an  acquired  deformity. 
The  diagnosis  between  the 
two  affections  may  be 
easily  made  on  the  physi- 
cal signs  alone.  In  conge- 
nital dislocation,  if  the  leg 
be  flexed  and  adducted  to 
its  extreme  limit,  the  head 
and  neck  of  the  displaced 
bone  can  be  distinguished 
beneath  the  distended 
tissues  of  the  buttock. 
In  coxa  vara,  nothing  but 

the  prominent  trochanter  can  be  made  out  on  similar  manipulation,  while 
the  abnormal  mobility,  characteristic  of  the  dislocation,  is  absent. 

Treatment. — If  the  deformity  were  discovered  in  the  early  stage, 
one  might  hope  to  check  its  progress  by  a  change  in  the  surroundings 
and  occupation  of  the  patient.  Standing,  particularly  in  the  attitude 
of  rest,  which  throws  additional  weight  upon  the  weakened  part,  should 
be  avoided,  and  work  of  any  kind  that  induces  the  familar  symptoms 
of  strain  should  be  discontinued.  As  much  time  as  possible  should  be 
spent  in  the  open  air,  and  diet  and  proper  therapeutic  remedies  should 
be  employed  if  evidence  of  constitutional  weakness  or  rhachitis  is  pres- 
ent. Locally  massage  of  the  limbs  and  joints  and  forcible  manipula- 
tion, with  the  aim  of  overcoming  as  much  of  the  adduction  as  may  de- 
pend upon  the  secondary  changes  in  the  soft  parts,  should  be  employed, 
reinforced  by  regular  gymnastic  exercises  of  the  legs,  with  the  object 


Double  coxa  vani,  of  advanced  degree,  showing  the  involun- 
tary crossing  of  the  legs  in  flexion. 


400 


COXA  VARA. 


of  improving  the  circulation  upon  which  the  repair  of  the  weakened 
bone  depends. 

In  most  instances  of  unilateral  deformity  temporary  support  is  indi- 
cated.    A  perineal  crutch  (Fig.  204)  or,  if  the  circumstances  of  the 
patient  permit,  one  of  the  convalescent  hip 
splints  that  allows  motion  at  the  knee,  may  pf^^.   279 

be  used.  (Fig.  205.)  With  support  dur- 
ing the  time  of  greatest  strain,  that  is, 
when  continuous  walking  or  standing  may 
be  required,  combined  with  proper  exer- 
cises and  massage,  the  weak  part  may  be- 

Fio.  278. 


Unilateral  coxa  vara,  showing  the 
eflfect  of  slight  depression  of  the  neck 
of  the  left  femur  upon  the  attitude. 

(bee  tig.  279.) 


The  patient,  Fig.  278,  eight  months 
after  cuueiforni  osteotomy.  An  abso- 
lute cure  both  as  regards  symptoms  and 
deformity.    See  skiagram  (Fig.  280). 


come  sufficiently  strong  to  perform  its  function  in  a  year  or  more,  but 
supervision  will  be  necessary  for  a  much  longer  time. 

Operative  Treatment. — When  the  deformity  has  advanced  so  that  the 
leg  is  permanently  adducted,  operative  treatment  is  indicated. 

Linear  Osteotomy. — The  simplest  and  most  efficient  means  of 
overcoming  the  adduction  in  older  subjects  is  linear  osteotomy  of  the 


OPERATIVE  TREATMENT.  401 

shaft  of  the  femur  just  below  the  trochanter  minor.  This  may  be  per- 
formed, by  the  subcutaneous  method,  as  in  the  correction  of  the  de- 
formity of  hip  disease.  When  the  bone  has  been  divided  the  shaft  is 
rotated  inward  until  the  foot  is  brought  to  the  normal  attitude  and  it 
is  then  abducted  to  the  normal  limit ;  in  this  attitude  a  plaster  spica 
bandage  is  applied  reaching  from  the  axilla  to  the  toes. 

If  the  deformity  is  bilateral  it  is  often  sufficient  to  operate  on  the 
leg  which  is  most  affected.  When  the  fracture  is  consolidated,  mas- 
sage, exercises  and  support  are  employed  as  has  been  described.  It 
may  be  assumed  that  the  increased  blood  supply  necessitated  by  the 
repair  of  the  injury  will  affect  favorably  the  weakened  bone  as  well. 

Fig.  280. 


Skiagnuu  ofpiitient,  Figs.  278  iiud  279.     lUuslratiug  the  ellect.  ol'  Lhe  operiiliou  iu  repliiciiig  the 
neck  of  the  femur  in  its  normal  position. 

The  final  result  in  two  cases,  in  which  the  operation  was  performed  by 
the  writer,  was  very  satisfactoiy. 

Cuneiform  Osteotomy. — In  youistgee  patients  the  deformity  may 
be  remedied  and  its  progress  checked  by  removal  of  a  cuneiform  sec- 
tion of  bone  from  the  upper  extremity  of  the  shaft  at  the  level  of  the 
trochanter  minor.  (Fig.  281.)  In  childhood  the  neck  of  the  femur  is 
short  and  the  strain  to  which  it  is  likely  to  be  subjected  slight,  thus  op- 
erative treatment  may  be  indicated  as  a  prophylactic  measure  while  in 
adolescence  operative  treatment  may  be  deferred  until  the  progression 
of  the  deformity  has  ceased. 

jJJEn  the  technique  of  this  procedure  there  are  several  points  of  im- 
portance.    First,  all  restriction  of  abduction,  of  ligamentous  or  mus- 
26 


402  COXA  VARA. 

cular  origin,  must  be  overcome  by  vigorous  manipulation  before  the 
operation  on  the  bone,  otherwise  it  will  be  difficult  to  bring  the  two 
fragments  into  proper  apposition.  The  base  of  the  wedge  should  be 
about  three-quarters  of  an  inch  in  breadth,  directly  opposite  the  tro- 
chanter minor ;  the  upper  section  should  be  practically  at  a  right  angle 
with  the  shaft,  the  lower  being  more  oblique.  (Fig.  281,  2.)  The  cor- 
tical substance  on  the  inner  aspect  of  the  bone  should  not  be  divided, 
but,  reinforced  by  the  cartilaginous  trochanter  minor,  should  serve  as  a 
hinge  on  which  the  shaft  of  the  femur  is  gently  forced  outward,  until 
the  opening  is  closed  by  the  apposition  of  the  fragments  after  the  up- 
per segment  has  been  fixed  by  contact  with  the  margin  of  the  acetab- 
ulum (Fig.  281 ,  3) ;  thus  the  continuity  of  the  bone  is  preserved.  The 
leg  is  then  held  in  the  attitude  of  extreme  abduction,  by  means  of  a 
plaster  spica  bandage,  which  should  include  the  foot  also,  until  the  union 
is  firm. 

The  opportunity  for  treatment  of  coxa  vara,  in  earliest  childhood,  is 
rarely  offered.  It  is  usually  the  direct  result  of  rhachitis  and  in  the 
early  stage,  at  least,  it  is  probably  accompanied  by  other  rhachitic  dis- 
tortions. It  would  be  well,  therefore,  to  examine  the  hip  joints  of 
rhachitic  children,  especially  those  who  present  the  deformity  of  genu 
valgum  with  reference  to  this  distortion.^ 


FRACTURE    OF    THE    NECK    OF   THE  FEMUR. 
Traumatic  Coxa  Vara. 

Fracture  of  the  neck  of  the  femur  in  childhood,  although  until  re- 
cently unrecognized,  is  by  no  means  an  uncommon  accident,  since 
seventeen  cases  have  come  under  the  waiter's  observation  during  the 
past  nine  years. 

Fracture  of  the  neck  of  the  femur  in  childhood,  how^ever,  differs 
markedly  in  its  symptoms  and  in  its  effects  from  that  in  later  life. 
In  childhood  the  immediate  effects  of  the  injury  are  far  less  disabling 
and  the  patient  is  often  able  to  walk  about  within  a  few  days  after  the 
accident,  from  which  it  may  be  inferred  that  there  is,  in  many  instances, 
a  bending  and  breaking  of  the  neck  without  actual  separation  of  the 
fragments.  During  the  period  of  repair  the  limp  and  attendant  dis- 
comfort are  usually  mistaken  for  symptoms  of  hip  disease. 

The  diagnosis  is  usually  simple.  In  all  the  cases  there  is  a  history 
of  injury,  usually  a  fall  from  a  height,  which  confined  the  patient  to 
the  bed  for  several  days  or  weeks.  On  physical  examination  shorten- 
ing of  half  an  inch  to  an  inch  is  found,  explained  by  the  corresponding 
elevation  of  the  trochanter.  Motion  in  the  joint  is  more  or  less  re- 
strained by  voluntary  and  involuntary  contraction  of  the  muscles,  but 
this  restriction  is  much  more  marked  in  flexion,  abduction  and  inward 
rotation  than  in  other  directions  ;  a  limitation  explained  by  the  nature 

-The  bibliography  of  the  subject,  to  the  extent  of  127  references,  may  be  found  in 
a  recent  article  by  Wagner  in  Zeits.  fiir  Orth.  Chir.,  Bd.  Vlil.,  H.  2,  1900. 


TRAUMATIC  COXA    VARA. 


403 


of  the  displacement,  the  neck  of  the  bone  having  been  forced  down- 
ward and  backward. 

The  immediate  effect  of  the  injury  is,  as  has  been  stated,  less  marked 
than  in  the  adult,  but  the  tendency  of  the  deformity  is  to  increase  in 
later  years,  because  the  right-angled  relation  of  the  neck  to  the  shaft 
exposes  it  to  greater  strain.  In  a  number  of  the  patients  examined 
several  years  after  the  injury,  there  was  an  increase  of  the  actual 
shortening  combined  with  permanent  adduction.  At  this  time  the  de- 
formity could  not  have  been  distinguished,  except  for  the  history,  from 
the  ordinary  coxa  vara  of  a  rather  extreme  degree. 

The  treatment  of  the  fracture  of  the  neck  of  the  femur,  if  the  diag- 
nosis is  made  immediately  after  the  accident,  should  include  an  attempt 

Fig.  281. 


1,  the  normal  femur  ;  2,  depression  of  the  neck  of  the  femur— coxa  vara  ;  A,  a  wedge  of  bone  has 
been  removed  ;  3,  abduction  of  the  limb  first  fixes  the  upper  segment  by  contact  with  the  rim  of  the 
acetabulum,  then  closes  the  opening  in  the  bone  ;  4,  replacement  of  the  limb  after  union  is  completed 
elevates  the  neck  to  its  former  position. 

to  replace  the  neck  in  its  proper  relation  with  the  shaft  in  order  that 
subsequent  deformity  may  be  prevented.  This  may  be  accomplished, 
if  at  all,  by  forcing  the  limb  into  abduction  while  traction  is  exerted, 
and  in  this  position  a  plaster  bandage,  reaching  from  the  axilla  to  the 
toes,  should  be  applied. 

After  consolidation  of  the  fracture  a  traction  hip  splint  may  be  worn 
for  several  months  or  until  complete  repair  has  taken  place.  Massage 
and  forcible  manipulation,  if  limitation  of  motion  remains,  combined 
with  the  avoidance  of  over-strain,  may  prevent  the  increase  of  the  de- 
formity. Otherwise  the  neck  of  the  femur  should  be  replaced  in  its 
normal  position  by  the  removal  of  a  sufficient  wedge  of  bone  from  the 


404  COXA  VARA. 

base  of  the  trochanter  as  described  under  the  treatment  of  simple  coxa 
vara.     (Fig.  281.) 

Traumatic  Separation  of  the  Epiphysis  of  the  Head  of  the  Femur. — 
As  has  been  stated,  in  traumatic  depression  of  the  neck  of  the  femur 
the  bone  breaks  or  bends  at  about  the  center  of  the  neck,  which  in  child- 
hood is  but  little  more  than  an  inch  in  length.  In  exceptional  cases 
the  head  of  the  femur  may  be  separated  at  the  epiphyseal  line.  This 
disjunction  is  more  likely  to  occur  in  adolescence  and  particularly  in 
subjects  suffering  from  coxa  vara  in  the  early  stage.  Thus  sudden 
disability,  following  slight  injury,  in  an  adolescent  who  has  complained 
of  discomfort  and  limp  for  some  time  before  and  who  presents  on  ex- 
amination the  signs  of  depression  of  the  neck  of  the  femur,  would  lead 
one  to  consider  the  possibility  of  this  accident ;  but  the  diagnosis  could 
be  established  only  by  a  Roentgen  picture  or  by  operation.^ 

The  treatment  is  similar  to  that  of  fracture,  but  the  functional  de- 
rangement of  the  joint  is  likely  to  be  greater  for  the  reason  that  the 
articulating  surface  of  the  head  of  the  femur  is  involved.^ 

1  Sprengel,  Archiv  f.  Klin  Chir.,  Bd.  47,  S.  805,  1898  ;  Clarke,  Lancet,  Oct.  27,  1900. 

2  Whitman,  The  Medical  Eecord,  Julv  25,  1893  ;  Annals  of  Surgery,  June,  1897. 
and  February,  1899. 


CHAPTER    XV. 

DEFORMITIES   OF   THE   BONES   OF   THE   LOWER 
EXTREMITY. 

Of  the  distortions  of  the  lower  extremity  bow  leg  and  knock  knee 
are  by  far  the  most  common,  comprising  about  15  per  cent,  of  the  total 
cases  in  orthopaedic  clinics.  Of  the  two,  bow  leg  is  the  more  frequent 
in  all  tables  of  statistics,  and  it  is  probable  that  the  proportion  of  bow 
leg  to  knock  knee  is  much  larger  than  would  appear  from  the  hospital 
records ;  for  genu  valgum  is  generally  recognized  as  a  serious  deform- 
ity, while  bow  leg  is  known  to  be  of  little  consequence  except  from  the 
aesthetic  standpoint,  so  that  its  rectification  is  more  often  trusted  to  the 
power  of  nature. 

Both  deformities  appear  to  be  more  common  in  male  than  in  fe- 
male children,  a  fact  explained  perhaps  by  the  greater  weight  and  the 
greater  susceptibility  of  the  former.  But  here  again  statistics  may  be 
influenced  somewhat  by  the  fact  that  bow  legs  are  considered  to  be  of 
more  consequence  to  the  boy  than  to  the  girl  because  of  the  conceal- 
ment that  the  skirts  will  insure,  if  the  distortion  is  not  outgrown  in 
childhood. 

Statistics. — The  relative  frequency  of  the  two  deformities  may  be  in- 
dicated by  the  statistics  of  the  Hospital  for  Ruptured  and  Crippled  for 
the  past  ten  years.  During  this  time  5,441  cases  were  recorded,  3,452 
cases  of  bow  legs  (63.4  per  cent.),  1,989  of  knock  knees  (37.6  per  cent.). 
Of  the  3,452  cases  of  bow  legs,  2,030  were  in  males  (58.8  per  cent.)  and 
1,422  were  in  females  (42.2  per  cent.).  The  1,989  cases  of  knock 
knees  were  more  evenly  divided  between  the  sexes,  1,024  being  in 
males  (51.4  per  cent.)  and  965  in  females  (48.6  per  cent.). 

Bow  Legs. 


Year. 

No.  cases. 

Males. 

Females. 

Over  21. 

Over  14. 

1 

1899 

400 

236 

164 

0 

5 

2 

1898 

406 

255 

151 

0 

2 

3 

1897 

467 

268 

199 

4 

1 

4 

1896 

356 

200 

156 

0 

1 

5 

1895 

336 

200 

136 

2 

1 

6 

1894 

310 

170 

140 

2 

7 

1893 

262 

157 

105 

3 

8 

1892 

306 

189 

117 

2 

9 

1891 

303 

174 

129 

1 

10 

1890 

306 

181 

125 

3 

3,452 

2,030 

1,422 

13 

21 

406 


DEFORMITIES  OF  BONES  OF  LOWER  EXTREMITY. 


Knock  Knees. 


Year. 

No.  cases. 

Males. 

Females. 

Over  21. 

Over  14. 

1 

1899 

202 

120 

82 

1 

4 

2 

1898 

233 

135 

98 

0 

11 

3 

1897 

222 

120 

102 

2 

5 

4 

1896 

232 

101 

131 

0 

0 

5 

1895 

210 

109 

101 

0 

2 

6 

1894 

212 

86 

126 

0 

0 

7 

1893 

162 

80 

82 

1 

2 

8 

1892 

168 

89 

79 

8 

2 

9 

1891 

189 

92 

97 

1 

2 

10 

1890 

159 

92 

67 

3 

3 

1,989 

1,024 

965 

16 

29 

It  will  be  noted  that  45  of  the  cases  of  genu  valgum  were  in  patients 
more  than  14  years  of  age,  as  compared  with  34  cases  of  adolescent  or 
adult  bow  legs.  The  writer's  personal  experience  in  the  clinic  enables 
him  to  state  that  a  large  proportion  of  the  cases  of  genu  valgum  actu- 
ally developed  or  increased  to  an  extent  demanding  treatment  during 
adolescence,  while  most  of  the  cases  of  bow  leg  deformity  in  patients 
more  than  14  years  of  age  had  existed  since  early  childhood  or  were 
the  result  of  injury  or  disease. 

The  Etiology  of  Genu  Valg-um,  Genu  Varum  and  of  Other  Dis- 
tortions of  the  Bones  of  the  Lower  Extremity. — The  common  pre- 
disposing cause  of  simple  deformities  and  disabilities  of  the  lower  ex- 
tremities, in  other  words  those  not  caused  by  local  injury  or  local  disease, 
is  the  erect  posture,  when  for  any  reason  the  bones  and  the  joints  are 
unequal  to  the  strain  of  locomotion  and  to  the  task  of  sustaining  the 
weight  of  the  body. 

i'"  Time  of  Onset, — At  two  periods  of  life  the  deformities  under  con- 
sideration most  often  develop.  The  first  is  in  early  childhood,  when 
the  upright  posture  is  first  assumed  ;  the  second  is  in  adolescence, 
when  the  rapid  growth  and  other  changes  incident  to  this  period  may 
lessen  the  stability  of  the  supporting  structures,  and  when  the  strain 
of  laborious  occupation  may  be  added  to  that  of  the  increasing  weight 
of  the  body. 

The  deformities  of  adolescence  are,  however,  relatively  insignificant 
in  number  compared  with  those  of  early  childhood,  for  in  childhood 
inherited  weakness  or  weakness  that  is  the  direct  result  of  malnutri- 
tion, at  once  develops  into  deformity  under  the  strain  of  standing  and 
walking.  Thus,  as  a  rule,  the  deformities  under  consideration  first  at- 
tract attention  soon  after  the  child  begins  to  walk,  and  the  patients  are 
usually  brought  for  treatment  during  the  second  or  third  year  of  life. 
If  the  deformities  are  severe,  the  body  usually  presents  the  evidences 
of  general  rhachitis ;  in  other  instances  the  distortion  of  the  legs  is 
the  only  sign  of  its  presence,  and  in  other  cases  there  may  be  no  evi- 
dence whatever  of  malnutrition  or  disease. 

Predisposition  to  Deformity. — It  is  not  always  easy  to  explain 
why   weak  legs  bend  in  one  way  rather  than  in  another.      In  some 


ETIOLOGY. 


407 


instances  it  is  probable  that  a  slight  degree  of  deformity  is  present 
before"'  the  child  begins  to  walk.  For  example,  a  slight  outward  bow- 
ing of  the  legs  is  said  to  be  common  in  early  infancy,  and  the  use  of 
heavy  diapers  might  favor  a  continuation  of  the  distortion.  Knock 
knee  may  be  induced,  apparently,  by  holding  the  infant  on  the  arm 
with  the  knees  pressed  against  the  chest,  and  certain  cases  of  knock 
knee  and  bow  leg  combined  appear  to  be  caused  directly  by  this  manner 
of  carrying  the  infant  habitually  upon  one  arm. 

The  legs  of  rhachitic  children,  who  have  never  walked,  are  often 


Fig.  282. 


Habitual  posture  as  a  factor  in  the  etiology  of  rhachitic  bow  leg. 

somewhat  distorted  and  in  many  instances  this  may  be  explained  by 
the  habitual  postures.     (Fig.  282.) 

A  moderate  degree  of  bow  leg  is  not  infrequently  seen  in  vigorous 
infants  who  stand  and  walk  at  an  early  age.  Aside  from  the  deter- 
mining curve  in  the  bone  that  may  be  present  before  the  child  be- 
gins to  walk,  this  predisposition  toward  bow  leg  may  be  explained, 
perhaps,  by  the  fact  that  young  infants  often  separate  the  feet  widely 
in  walking  and  the  swaying  of  the  body  from  side  to  side  may  tend  to 
bend  the  legs  outward.  In  weaker  or  less  vigorous  children  a  slight 
degree  of  knock  knee  is  not  uncommon,  induced,  it  may  be,  by  weak- 


408 


BEFOBMTTIES  OF  BONES  OF  LOWER  EXTREMITY. 


Fig.  283. 


; 


ness  or  inactivity  of  the  muscles,  as  a  result  of  which  the  child  stands 
with  the  knees  somewhat  flexed  and  pressed  together,  while  the  feet 
are  separated  and  everted,  an  exaggeration  of  the  so-called  attitude  of 
rest. 

Bow  leg  is  not  uncommon  in  adult  life  and  it  is  popularly  associated 
with  strength  and  activity.  Undoubtedly  the  attitudes  of  activity  favor 
the  production  of  bow  leg  rather  than  knock  knee,  so  that  this  tradi- 
tion may  have  a  foundation  of  truth.  It  is  said  to  be  common  among 
those  who  ride  constantly  and  it  may  be  a  direct  result  of  injury  or  dis- 
ease of  the  knee  joint,  but  it  may  be  stated  that  well-marked  bow  leg 
in  an  adult  is  almost  always  a  deformity  that  has  existed  since  child- 
hood.    This  statement  cannot  be  made  of  genu  valgum,  since  it  may 

develop  or  increase  during  ado- 
lescence or  even  in  adult  life.  The 
predisposing  cause  is  weakness  or 
overstrain,  and  as  has  been  stated 
in  the  popular  mind  the  deformity 
is  characteristic  of  weakness. 

The  Attitude  of  Eest. — Genu 
valgum  is  an  exaggeration  of  what 
is  known  as  the  attitude  of  rest 
or  relaxation,  in  which  the  weight 
of  the  body  is  thrown  in  great  part 
upon  the  ligaments  of  the  three 
joints  of  the  lower  extremity.  In 
the  attitude  of  rest  the  pelvis  is 
tilted  forward,  the  femora  are  ro- 
tated inward  upon  the  tibise  and  the 
feet  are  separated  and  everted,  so 
that  the  greatest  strain  falls  upon 
the  inner  side  of  the  knees  and  of 
the  feet.  Thus,  what  is  known  as 
flat  foot  is  often  combined  with 
knock  knee;  knock  knee  may  cause 
flat  foot,  but  more  often  the  flat  foot 
may  induce  knock  knee,  or  both  may 
be  the  effect  of  the  same  general  cause.  Genu  valgum,  in  the  slighter 
degree  at  least,  may  be  induced  directly  by  an  improper  attitude,  but 
the  attitude  is,  as  a  rule,  the  result  of  over-work  to  which  the  mechan- 
ism is  subjected ;  thus  the  knock  knee  of  adolescence  is  so  common 
among  the  bakers  of  Vienna,  that  "  baker's  knee  "  is  there  synonymous 
with  genu  valgum. 

Genu  valgum  may  be  secondary  to  distortion  elsewhere.  For  ex- 
ample, compenss^' ory  knock  knee  is  usually  combined  with  extreme  ad- 
duction of  the  thigh ;  it  may  be  the  result  of  the  inactivity  necessitated 
by  the  treatment  of  hip  disease ;  it  may  be  a  direct  result  of  injury,  and  it 
is  sometimes  an  accompaniment  of  osteomyelitis  or  osteoperiostitis  of  the 
ibia,  which  causes  an  overgrowth  and  abnormal  lengthening  of  the  leg. 


A  type  of  deformity  in  which  the  prognosis  as 
regards  outgrowth  is  bad. 


THE  OUl GROWTH  OF  DEFORMITY.  409 

The  Outgrowth  of  Deformity. — In  considering  the  treatment  of 
the  simple  static  deformities  of  the  lower  extremity  which  are  usually 
the  result  of  a  temporary  weakness  of  structure,  one  must  first  answer 
the  question,  "Will  not  the  child  outgrow  it?"  This  belief  in  the 
spontaneous  cure  of  deformity  is  very  strong  not  only  among  the  laity 
but  among  physicians  as  well ;  and  it  rests  upon  the  common  observa- 
tion that  crooked  legs  become  straight,  or  at  least  less  deformed,  with 
the  growth  of  the  child.  In  fact  if  one  were  to  judge  from  the  general 
observation  of  the  effect  of  growth  upon  the  deformities  of  this  class,  or 
even  from  the  tracings  of  the  legs  of  rhachitic  children  taken  from 
year  to  year,  one  might  conclude  that  all  deformities  of  this  class  might 
be  safely  left  to  themselves.  As  an  illustration  of  positive  evidence  on 
the  subject,  the  observations  of  Kamps,^  on  32  cases  of  rhachitic  dis- 
tortion of  the  lower  extremity,  may  be  cited.  Four  and  one-half  years 
after  the  cases  were  first  seen  and  recorded,  examination  showed  that 
75  per  cent,  were  cured,  15.3  per  cent,  improved,  while  9.7  per  cent, 
were  unimproved.  His  conclusions  are  that  such  deformities  do  not, 
as  a  rule,  require  special  treatment  in  early  childhood,  but  that  after  the 
age  of  six  years  the  prognosis  for  spontaneous  cure  is  unfavorable. 

Veit  ^  photographed  a  number  of  rhachitic  children  seen  in  the  sur- 
gical clinic  of  the  University  of  Berlin,  and  after  a  lapse  of  two  or 
three  years  made  another  series  of  photographs  of  the  same  patients, 
who  had  meanwhile  received  no  treatment.  His  conclusions  are  simi- 
lar to  those  of  Kamps,  namely,  that  surgical  treatment  is  not  required 
for  deformity  of  this  character  in  children  less  than  six  years  of  age. 
In  two  classes  of  cases,  however,  the  prognosis  for  spontaneous  cure  is 
not  favorable,  those  in  which  the  growth  has  been  checked  by  the  rha- 
chitic process,  and  in  certain  cases  of  extreme  bow  legs,  "O"  legs. 
(Fig.  283.) 

The  rectifying  force  of  nature  acts  in  two  ways.  Assuming  that  the 
deformity  reached  its  limit  during  the  period  of  original  weakness,  it 
must  of  course  become  relatively  less  as  the  body  increases  in  length 
and  size.  In  fact  the  outgrowth  of  deformity  has  a  direct  relation  to 
the  rapidity  of  growth  during  the  early  years  of  childhood.  The 
second  manifestation  of  the  power  of  nature  is  more  positive.  It  may 
be  assumed  that  when  the  deformity  is  progressive  all  the  tissues  are 
afi^ected  by  the  weakness,  consequently  the  attitudes  of  the  child  are 
those  that  can  be  most  easily  assumed  under  the  abnormal  conditions. 
But  when  the  primary  cause  of  the  weakness,  in  most  instances  rhachi- 
tis,  is  no  longer  operative,  the  muscles  take  on  new  activity  and  vigor 
and  the  actions  and  attitudes,  in  spite  of  the  deformity,  become  ap- 
proximately normal.  Then  according  to  Wollf 's  law  of  transformation 
the  internal  structure  of  the  affected  bones  begins  to  change  to  accom- 
modate itself  to  the  new  conditions  of  weight  and  stra*"-  induced  by  the 
change  in  action  and  attitude ;  and  to  this  rearrangement  of  the  inter- 
nal structure,  the  external  shape  of  the  bones  must  conform  in  a  grad- 
ual growth  toward  the  normal  contour. 

iBeitriige  zur  Klin.  CMr.,  Bd.  14,  H.  1. 
2  Archiv  f.  Klin.  Chir.,  Bd.  50,  S.  130. 


410 


DEFOBMIIIES  OF  BONES  OF  LOWER  EXTREMITY. 


On  this  theory,  it  is  easily  explained  how  the  natural  outdoor  life 
of  the  country  has  long  been  celebrated  as  an  effective  treatment  for 
this  class  of  deformity.  But  it  by  no  means  follows  that  deformity 
is  always  outgrown,  even  under  favorable  conditions.  Improper  atti- 
tudes, that  favor  and  cause  deformity,  are  often  observed  among  those 
who  are  free  from  weakness  and  disability  and  from  the  influences  of 
unfavorable  surroundings  ;  and  such  attitudes  are  of  course  more 
likely  to  persist  in  those  who  were  once  obliged  to  assume  them  be- 
cause of  weakness  and  defor- 
FiG.  284.  mity.    Again,  the  weakness  of 

structure  or  function  may  be 
an  inherited  peculiarity,  or  it 
may  be  induced  by  disease  or 
by  improper  surroundings,  in- 
fluences that  may  continue  for 
many  years  and  thus  serve  to 
check  the  natural  tendency 
toward  cure. 

The  observations  on  the 
outgrowth  of  deformity  have 
been  confined,  as  a  rule,  to  the 
period  of  childhood,  and  most 
often  they  have  been  made 
with  reference  to  the  more 
serious  grades  of  distortion, 
which  are  the  direct  result  of 
rhachitis. 

It  must  be  borne  in  mind, 
however,  that  the  true  signifi- 
cance of  these  deformities  in 
the  adult  must  be  judged  from 
the  sesthetic,  rather  than  from 
the  medical  point  of  view,  and 
although  the  extreme  degrees 
of  bow  leg  and  knock  knee  are 
relatively  rare  yet  in  the  minor 
grade  both  deformities  are  \e.vy 
common  in  adult  males  and 
in  all  probability  in  adult  fe- 
males also. 
In  1887  the  writer^  noted  among  2,000  adult  males  observed  on 
the  streets  of  Boston,  400  cases  of  bow  leg  and  32  cases  of  knock 
knee.  One  may  assume  then  that  the  legs  of  about  one  adult  male  in 
five  deviate  more  or  less  from  the  line  of  symmetry,  a  conclusion  that 
has  been  confirmed  by  many  subsequent  observations.  It  may  be  ad- 
mitted that  a  certain  number  of  the  distortions  under  consideration  are 
acquired  during  adolescence,  but  it  is  probable  that  the  greater  num- 

»N.  Y.  Med.  Eec,  July  30,  1887. 


Extreme  deformities,  the  result  of  infantile 
rhachitis.  The  leg  forms  practically  a  right  angle 
with  the  thigh.     (See  Fig.  288. ) 


GENU  VALGUM. 


411 


ber  of  those  that  may  be  noted  in  walkers  upon  the  streets  represent 
the  incomplete  outgrowth  of  a  deformity  of  childhood. 

The  statement  is  often  made  that  these  distortions  of  the  legs  are 
common  in  childhood  but  rare  in  adult  life.  Just  what  the  proportion 
may  be  in  childhood  it  is  impossible  to  say,  but  it  is  not  likely  to  be 
greater  than  one  in  five.  One  must  conclude  that  statistics,  on  which 
such  statements  are  based,  have  been  made  up  from  the  records  of  hos- 
pitals where  it  is  extremely  uncommon  for  an  adult  to  apply  for  the 
treatment  of  bow  leg,  to  which  he  has  become  accustomed  since  child- 
hood, unless  the  deformity  is  very  extreme  or  is  attended  by  pain. 

Granting  that  the  power  of  nature  is  quite  sufficient  to  modify,  or  to 
cure  even  the  more  extreme  distortions  of  childhood,  still  it  would  seem 
that  this  natural  force  is  often  ineffective  in  completing  the  cure.  There- 
fore in  doubtful  cases,  at  least,  one  should  lend  assistance  in  that  class 
of  patients  likely  to  appreciate  the  advantage  of  symmetry  over  slight 
deformity,  even  though  it  be  unattended  by  discomfort  or  disability. 

Genu  Valgum. 

Synonyms. — Knock  Knee,  In  Knee. 

In  the  erect  posture  the  thighs,  whose  upper  extremities  are  sepa- 
rated by  the  pelvis  and  by  the  projecting  femoral  necks,  incline  slightly 
inward  to  the  knees,  forming  an  angle  at  the  knee,  opening  outward. 


Fig.  285. 


Fia.  286. 


Female.  Male. 

The  normal  iiicliuatiou  of  tlie  I'emuiii.     (1'1'I:iffku.  ) 


of  about  172  degrees.  This  angle  varies  with  the  breadth  of  the  pelvis, 
and  it  is  therefore  less  in  adult  females  than  in  males.  (Figs.  285, 
286.)  The  internal  condyle  of  the  femur  is  slightly  longer  than  the 
external,  thus  the  inclination  of  the  femur  is  compensated  and  the 
plane  of  the  knee  joint  is  horizontal. 


412  DEFORMITIES  OF  BONES  OF  LOWER  EXTREMITY. 

Wheu  the  inward  projection  of  the  knees  is  increased  to  a  noticeable 
degree  the  tibiae  are  no  longer  perpendicular,  their  upper  extremities 
incline  inward  so  that  in  the  erect  posture  the  feet  are  separated  when 
the  knees  are  in  contact.  (Fig.  287.)  In  the  slighter  grades  of  knock 
knee,  which  are  due  in  great  degree  to  laxity  of  the  ligaments,  the  de- 
formity is  apparent  only  when  the  weight  of  the  body  is  borne,  but  in 
more  marked  cases,  although  the  distortion  is  increased  by  the  weight 
of  the  body,  it  can  not  be  overcome  when  this  is  removed  because  it 
depends  upon  actual  changes  in  the  shape  of  the  bones  themselves. 

Fig.  287. 


Adolescent  knock  knees.    Deformity  most  marked  in  tlie  tibiae.    (See  Fig.  290.) 

As  has  been  stated,  the  normal  inward  inclination  of  the  femur  is 
compensated ,  by  the  greater  length  of  the  internal  condyle,  and  in  the 
deformity  of  knock  knee  the  plane  of  the  knee  joint  is  still  preserved 
by  an  apparent  elongation  of  the  inner  condyle.  Formerly  it  was  sup- 
posed that  there  was  an  actual  over-growth  of  this  part  of  the  epiphysis, 
which  caused  the  deformity,  but  the  observations  of  Mickulicz  and 
Macewen  have  shown  that  this  apparent  lengthening  is  in  reality  due, 
in  great  part,  to  a  deformity  of  the  lower  extremity  of  the  shaft  of  the 


GENU  VALGUM. 


413 


femur,  which  is  so  bent  that  the  epiphyseal  line  has  an  increased  obli- 
quity. •  And  the  hypothesis  that  bone  grows  more  rapidly  when  relieved 
from  weight  and  strain  has  been  disproved  by  Wollf,  who  has  shown 
that  changes  in  the  bones  are  the  result  of  accommodation  to  altered 
function  and  attitude.  (See  page  190.)  The  deformity  is  not  limited 
to  the  femur ;  in  most  instances  there  is  a  similar,  although  usually 
slighter,  irregularity  in  the  epiphyseal  line  of  the  upper  extremity  of 
the  tibia,  the  shaft  being  so  bent  that  when  it  is  placed  in  the  perpen- 

FiG.  288. 


Skiagram  of  Fig.  284  showing  the  deformity  to  be  due  to  distortions  of  the  diaphyses  of  the  bones 
while  the  epiphyses  are  practically  normal. 

dicular  position  its  internal  condylar  surface  is  higher  than  the  external. 
(Fig.  288.) 

Changed  Relation  of  the  Femur  and  Tibia. — In  addition  to 
the  direct  deformities  of  the  bones  there  is  a  change  in  the  relation  of 
the  femur  to  the  tibia.  The  former  is  rotated  inward  and  the  latter  is 
rotated  outward.  In  some  instances  there  is  also  a  certain  degree  of 
over-extension  at  the  knee.  This  is  more  often  observed  in  the  ado- 
lescent type  in  which  there  is  laxity  of  the  ligaments,  but  in  the  ordi- 
nary form  of  rhachitic  knock  knee  in  childhood,  the  habitual  attitude 
is  one  of  slight  flexion  at  the  knees  and  in  extreme  cases  there  may 


414 


DEFORMITIES  OF  BONES  OF  LOWER  EXTREMITY. 


Fig.  289. 


be  actual  limitation  of  the  range  of  extension  at  the  knee,  and  at  the 
hip  as  well. 

The  Accommodative  Attitude. — When  the  limb  is  fully  ex- 
tended, the  deformity  is  most  marked  because  the  shortened  ligaments 
and  tissues  on  the  outer  aspect  of  the  joint  become  tense,  and  because 
the  outward  rotation  of  the  tibia  is  increased.  As  the  leg  is  flexed  the 
deformity  lessens,  and  in  the  attitude  of  complete  flexion  it  disappears. 
(Fig.  290.)     This  is  explained  by  the  fact  that  the  posterior  surface 

of  the  condyles  is  not  affected  by  the 
deformity  of  the  shaft,  while  the 
relaxation  of  the  ligaments  and  the 
outward  rotation  of  the  femora  al- 
low the  tibiae  to  become  parallel  with 
one  another.  This  explains  the  ha- 
bitual attitude  of  slight  flexion  which 
is  so  often  assumed  by  patients 
who  thus  unconsciously  accommo- 
date themselves  to  the  deformity. 

Secondary  Deformities.  — 
The  outward  inclination  of  the  leg 
throws  more  weight  upon  the  inner 
border  of  the  foot  and  tends  to  de- 
press it  into  the  attitude  of  valgus. 
Thus  knock  knee  in  weak  children 
is  often  accompanied  by  flat  foot, 
but  in  the  more  extreme  grades  of 
deformity  the  efforts  of  the  patient 
to  compensate  for  the  abnormal 
separation  of  the  feet  may  result  in 
habitual  supination,  in  fact,  con- 
firmed and  extreme  knock  knee  is 
often  accompanied  by  a  slight  de- 
gree of  varus  that  becomes  very  evi- 
dent after  the  correction  of  the  de- 
formity by  operation.  Even  in  the 
mildest  type  of  knock  knee,  this 
compensatory  and  conservative  ef- 
fort of  nature  shown  by  the  so-called 
pigeon-toed  walk,  may  be  the  first 
symptom  that  attracts  attention. 
Gait. — The  gait  of  the  patient  with  well-marked  genu  valgum  is 
peculiarly  awkward  and  shambling.  The  knees  "  interfere  "  and  must 
be  assisted,  as  it  were,  in  the  effort  to  pass  one  another  in  walking.  In 
the  slighter  cases,  the  thigh  is  abducted  and  rotated  outward  at  the  mo- 
ment of  passing  its  fellow,  the  movement  being  then  reversed  as  it,  in 
its  turn,  suppc.i  ts  the  weight ;  but  in  the  more  severe  type  this  voluntary 
effort  of  the  muscles  of  the  leg  is  not  sufficient,  and  in  addition,  the 
body  is  swayed  from  side  to  side  and  the  legs  are  alternately  swung 
outward  and  liftgd  around  one  another. 


Deformity  of  the  femur  in  genu  valgum. 

(MiCKULICZ.) 


GENU  VALGUM. 


415 


The  deformity"  and  the  effects  of  the  deformity  on  the  gait  and  atti- 
tude ^re  the  most  important  symptoms,  as  of  other  distortions  of  simi- 
lar origin.  The  patient  is,  as  a  rule,  easily  fatigued,  and  pain  during 
the  progressive  stage,  referred  to  the  inner  side  of  the  knee  where  the 
ligaments  are  subjected  to  continuous  strain,  is  a  common  symptom,  par- 
ticularly in  the  adolescent  type  of  genu  valgum. 

Unilateral  Knock  Knee. — This  description  refers  particularly  to  the 
cases  in  which  the  deformity  is  bilateral.  Not  infrequently  it  is  uni- 
lateral, the  leg  being  so  shortened  by  the  distortion  that  a  well-marked 
limp  replaces  the  swaying  gait.     The  pelvis  is  tilted  toward  the  short 

Fig.  290. 


Adolescent  knock  knee,  showing  the  disappearance  of  the  deformity  when  legs  are  flexed 

(See  fig.  287.) 


leg,  while  the  body  is  inclined  in  the  opposite  direction,  so  that  in  cases 
of  long  standing,  a  permanent  curvature  of  the  lumbar  spine  may  be 
present. 

Knock  Knee  Combined  with  Bow  Leg  and  with  G-eneral  Rhachitic  Dis- 
tortions.— Occasionally  the  unilateral  knock  knee  may  be  accompanied 
by  an  outward  bowing  of  its  fellow ;  and  in  the  marked  distortions  of 
the  lower  extremity,  that  are  the  result  of  rhachitis,  the  bones  may  be 
twisted  and  bent  in  various  directions,  although  the  outward  expression 
of  the  deformity  may  be  genu  valgum.  For  example,  the  femora  may 
be  bent  forward  and  outward  above,  and  inward  and  backward  below, 
while  the  tibiae  may  be  bent  inward  above,  and  outward  and  forward 
below. 

In  other  instances,  especially  in  the  slighter  rhachitic  deformities,  an 
outward  bowing  of  the  tibiae  may  accompany  a  slight  degree  of  knock 
knees,  so  that  it  is  difficult  to  classify  the  deformity. 


416  DEFORMITIES  OF  BONES  OF  LOWER  EXTREMITY. 

In  the  more  extreme  deformities  of  the  rhachitic  type,  the  shape  as 
well  as  the  contour  of  the  bones  is  modified,  for  example,  the  internal 
border  of  the  tibia  may  become  very  prominent  at  its  upper  extremity, 
and  may  project  beneath  the  skin  like  an  exostosis.  (Fig-  291.)  A 
change  in  the  contour  of  the  fibula  accompanies  and  corresponds  to 
that  of  the  tibia  although  it  is,  as  a  rule,  much  less  pronounced.     As 

Fig.  291. 


Knock  knee  and  bow  leg. 


has  been  stated,  the  internal  structure  or  architecture  of  the  affected 
bones  is  changed  to  accommodate  the  new  static  conditions,  and  ac- 
cording to  Wollf  the  internal  change  precedes  the  external  deformity. 
Pathology. — In  knock  knee  due  directly  to  rhachitis  the  changes  in 
the  bones  and  in  the  epiphyseal  cartihiges  are  characteristic  of  that  af- 
fection, but  in  the  milder  grades  of  deformity,  aside  from  the  change  in 
the  contour  of  the  bones,  the  transformation  of  the  internal  structure, 


EXPECTANT  TREATMENT.  417 

and  in  some  instances  slight  thickening  or  irregularity  of  the  epiphyseal 
cartilage,  there  is  little  noteworthy  change  from  the  normal.  (Fig.  289.) 
The  tissues  on  the  internal  aspect  of  the  joint  are  relaxed,  those  on  the 
outer  side,  the  lateral  ligaments,  the  capsule  and  the  biceps  muscle,  are 
contracted  and  resist  the  reduction  of  the  deformity.  In  the  interior  of 
the  joint  slight  changes  in  the  articulating  surfaces  of  the  bones,  and 
evidences  of  chronic  irritation  of  the  synovial  membrane  have  been 
described. 

Measurements. — There  are  various  methods  of  measurins:  the  de- 
formity.  One  of  the  simplest  and  most  practical  is  to  trace  the  out- 
lines on  paper,  while  the  child  is  seated  with  the  legs  fully  extended, 
the  knees  being  sufficiently  separated  to  allow  the  pencil  to  pass  be- 
tween thera.  The  increase  of  the  deformity,  dependent  upon  the  lax- 
ity of  the  ligaments  and  upon  the  outward  rotation  of  the  tibiae,  may 
be  estimated  by  measuring  the  distance  between  the  two  internal  mal- 
leoli when  the  patient  stands,  the  knees  being  slightly  separated  as  be- 
fore and  comparing  this  measurement  with  that  between  the  similar 
points  in  the  tracing.  In  the  early  stage  of  progressive  knock  knee, 
particularly  in  the  type  not  caused  directly  by  rhachitis,  laxity  of  liga- 
ments and  the  habitual  assumption  of  the  attitude  of  rest,  will  account 
for  the  deformity,  which  the  patient  may  be  able  to  overcome,  in  great 
degree  at  least,  by  voluntary  eifort.  This  voluntary  control  of  the  de- 
formity is  very  suggestive,  as  indicating  certain  factors  in  its  etiology 
and  the  principles  that  should  be  followed  in  its  treatment. 

Treatment. — The  treatment  of  the  deformity  under  consideration 
may  be  classified  as  :  Expectant,  mechanical,  and  operative. 

Expectant  treatment  should  not  be  expectant  in  the  sense  that  noth- 
ing is  to  be  done  to  correct  the  deformity,  but  expectant  in  that  more 
positive  treatment  by  braces  or  by  operation  is  delayed,  or  avoided  if  it 
prove  to  be  unnecessary. 

During  the  expectant  period  the  cause  of  the  deformity,  if  it  is  consti- 
tutional, should  receive  proper  dietetic  or  medicinal  treatment  as  already 
described  in  the  chapter  on  rhachitis.  And,  if  possible,  the  direct  ex- 
citing causes  of  the  deformity  must  be  removed,  that  is  to  say,  the  im- 
proper attitudes  or,  in  the  adolescent,  the  predisposing  occupations 
should  be  discontinued.  General  massage  of  the  limbs  may  be  em- 
ployed with  advantage ;  in  older  children  special  exercises  may  be 
practiced,  and  in  all  cases,  whether  braces  are  used  or  not,  direct 
manipulation  of  the  distorted  limbs  is  of  the  first  importance. 

Manipulation. — In  the  slight  degrees  of  deformity,  more  espe- 
cially of  that  type  in  which  the  distortion  appears  to  be  due  to  simple 
weakness  rather  than  to  rhachitis,  the  expectant  treatment  may  be 
tested.  The  legs  should  be  vigorously  massaged  at  morning  and  night, 
and  forcibly  straightened.  The  latter  procedure  is  conducted  as  fol- 
lows :  the  patient  is  seated  in  a  chair,  the  limb  being  fully  extended  so 
that  the  deformity  is  made  as  extreme  as  possible.  One  hand  then 
clasps  the  knee,  the  palm  lying  against  its  inner  aspect ;  with  the  other, 
the  calf  is  grasped  firmly  and  the  leg  is  then  gently  straightened  over 
27 


418  DEFORMITIES  OF  BONES  OF  LOWER  EXTREMITY. 

the  fulcrum  formed  by  the  palm  of  the  hand,  and  is  held  in  the  corrected 
position  for  a  moment.  This  manipulation  should  be  continued  with 
gradually  increasing  force,  although  not  to  the  extent  of  causing  actual 
pain,  for  ten  minutes,  at  least  twice  in  the  day  and  oftener  if  possible. 
Posture  and  Exercise. — It  has  been  stated  that  genu  valgum  is 
often  accompanied,  especially  in  the  rhachitic  cases,  by  flat  foot,  while 
in  another  type  the  inversion  of  the  feet,  or  in  the  more  severe  cases 
the  actual  fixed  attitude  of  varus,  indicates  the  eifort  of  nature  to  with- 


FiG.  292. 


Fig.  293. 


The  Thomas  knock  knee  brace. 


Thomas  knock  knee  braces  with  pelvic  band. 


stand  and  to  compensate  for  the  deformity  at  the  knee.  This  serves  as 
an  indication  for  making  the  soles  of  the  shoes  thicker  on  the  inner 
side  as  in  the  treatment  of  flat  foot,  in  order  to  throw  the  strain  upon 
the  outer  border  of  the  foot.  The  patient  should  be  instructed  to  walk 
with  the  feet  parallel  with  one  another,  and  for  older  children  the  tip- 
toe exercises,  in  which  the  body  is  raised  upon  the  toes  as  many  times 
as  the  strength  permits,  or  games  or  exercises  in  which  the  legs  are 
extended  should  be  encourasred.     Such  exercises  are  often  efficacious 


MECHANICAL  TREATMENT. 


419 


in  the  parly  stage  of  adolescent  knock  knee,  for  as  has  been  mentioned, 
genu  valgum  is  an  exaggeration  of  the  attitude  of  rest,  therefore  its 
progress  should  be  checked  by  the  assumption  of  the  attitudes  proper 
to  activity.  A  careful  record  of  the  deformity  should  be  kept  during 
this  tentative  treatment  and  if  it  improves  somewhat,  one  is  justified 
in  delaying  the  more  radical  measures.  This  question  may  be  decided, 
as  a  rule,  in  three  months,  if  instructions  are  faithfully  followed. 

Fig.  294. 


Modified  Thomas  knock  knee  braces  applied. 

Treatment  by  Braces. — The  most  efficient  brace  in  the  treatment  of 
genu  valgum  is  the  simple  straight  steel  bar  or  splint  extending  from 
the  trochanter  to  the  heel  of  the  shoe,  without  joint  at  the  knee.  The 
greater  efficacy  of  the  rigid  bar  as  compared  with  the  jointed  brace  is 
explained  by  the  fact  that  the  rectifying  force  acts  constantly  when  the 
joint  is  fixed,  and  because,  in  many  instances,  the  patient  habitually 
flexes  the  knees  so  that  direct  pressure  cannot  be  made  upon  the  de- 
formity by  a  brace  that  allows  this  attitude. 


420 


DEFORMITIES  OF  BONES  OF  LOWER  EXTREMITY. 


Fig.   295. 


The  Thomas  Brace. — The  simplest  and  cheapest  brace  is  that  of 
Thomas,  which  consists  of  a  light  steel  bar  provided  with  a  pad  at  its 
upper  end  for  pressure  against  the  trochanter,  while  the  lower  rounded 
extremity  is  turned  inward  at  a  right  angle,  to  pass  through  the  heel  of 
the  shoe.  The  knee  is  fixed  by  a  posterior  bar  attached  to  a  thigh  and 
calf  band,  as  illustrated  in  the  figure.  When  the  brace  is  applied  the 
knee  is  drawn  backward  and  outward  and  is  attached  firmly  to  the 
brace  by  a  roller  bandage.     (Fig.  292.) 

In  the  more  extreme  cases  in  which  the  knees  and  thighs  are  ha- 
bitually flexed,  the  addition  of  a  pelvic  band  attached  to  the  uprights 

by  a  free  joint  at  the  hips,  adds  to  the 
comfort  and  efficiency  of  the  appara- 
tus, as  the  attitude  of  outward  or  in- 
ward rotation  can  be  regulated  by 
twisting  the  uprights  slightly.  Or 
the  pelvic  band  may  be  divided  and 
attached  by  means  of  straps  on  the 
front  and  back.  The  uprights  may  be 
bent  somewhat  inward  at  first,  and  as 
the  legs  become  straighter  they  are 
straightened  and  finally  bent  slightly 
outward  to  allow  for  the  over-correc- 
tion of  the  deformity.  (Fig.  294.) 
Twice  a  day  the  braces  should  be  re- 
moved to  allow  for  massage,  manipu- 
lation and  for  voluntary  exercises  of 
the  legs.  In  most  cases  the  braces  are 
not  employed  at  night,  although  the 
rectification  of  the  deformity  may  be 
hastened  by  their  constant  use. 

If  the  deformity  is  unilateral  so  that 
a  brace  is  required  for  one  leg  only,  the 
other  shoe  should  be  raised  by  a  cork 
sole  about  three  quarters  of  an  inch  in 
thickness  to  make  walking  easier. 
Children  soon  become  accustomed  to 
the  braces  and  walk  easily  in  spite  of 
the  absence  of  joints  at  the  knees. 
Another  simple  and  efficient  brace  is  that  used  at  the  Children's  Hos- 
pital at  Boston.  (Fig.  295.)  The  upper  part  of  the  brace  is  turned 
backward  and  upward  to  lie  against  the  buttock,  and  the  feet  can  be 
rotated  in  or  out  by  lengthening  or  shortening  straps  passing  before 
and  behind  the  body.  Braces  jointed  at  the  knee  are  sometimes  em- 
ployed, but  they  are,  as  a  rule,  ineffective  except  in  the  slighter  cases 
in  which  the  deformity  depends  upon  laxity  of  ligaments  rather  than 
distortion  of  bone. 

Duration  of  Treatment  by  Braces. — The  duration  of  the 
brace  treatment  depends,  of  course,  upon  the  degree  of  deformity,  the 


Long  braces  for  genu  valgum.     (Bradford 

AND    LOVETT.) 


OPERATIVE  TREATMENT.  421 

age  of  the  child  and  upon  the  efficiency  of  the  apparatus.  From  six 
months  to  one  year  of  treatment  by  this  means  is  usually  required. 
The  cure  is  assured  by  the  gradual  adaptation  of  the  parts  to  the 
new  static  conditions.  The  contracted  tissues  of  the  outer  aspect  of 
the  joint  become  lengthened  ;  the  lax  ligaments  on  the  inner  side  con- 
tract ;  the  internal  structure  of  the  condyles  and  of  the  adjoining  dia- 
physis  is  gradually  transformed  and  at  the  external  contour  of  the  bone 
becomes  correspondingly  straighter.  When  the  braces  are  discarded, 
attention  should  be  paid  to  the  attitudes,  and  the  exercises  that  have 
been  mentioned  should  be  continued  in  order  that  relapse  may  be  pre- 
vented. 

The  Plaster  Bandage. — When  the  bones  are  yielding,  as  in  the 
deformity  due  directly  to  rhachitis  in  young  children,  it  may  be  cor- 
rected rapidly  by  the  repeated  applications  of  plaster  bandages,  the  leg 
being  straightened  as  far  as  possible  without  causing  discomfort,  at  each 
sitting.    This  method  is  rarely  employed  except  in  dispensary  practice. 

Operative  Treatment. — Immediate  correction  of  the  deformity,  when 
it  is  at  all  marked,  is  as  a  rule  indicated  after  the  age  of  four  or  five  years. 
It  is  perhaps  needless  to  remark  that  the  necessity  for  operation  im- 
plies neglect  of  proper  preventive  treatment  or  the  failure  of  the 
manipulative  and  mechanical  methods  because  of  their  improper  appli- 
cation. While  it  is  possible  to  correct  deformity  of  the  bone  by  me- 
chanical treatment  in  cases  far  beyond  this  limit  of  age,  yet  the  time 
required  and  the  discomforts  of  the  treatment  exclude  it  in  all  but  very 
exceptional  cases. 

Osteotomy. — At  the  Hospital  for  Ruptured  and  Crippled,  osteotomy 
is  invariably  performed  in  the  treatment  of  genu  valgum  by  means  of 
the  small  Vance  osteotome,  the  so-called  "  subcutaneous  osteotomy." 
(Fig.  262.) 

The  limb  having  been  prepared  in  the  usual  manner  is  semiflexed  and 
the  inner  surface  of  the  knee  is  placed  on  a  firm  sand  bag.  With  the 
fingers  the  femur  is  firmly  grasped  just  above  the  condyles  so  that  its 
size  and  position  may  be  accurately  determined,  and  the  sharp  osteo- 
tome about  the  size  of  a  lead  pencil  is  forced  with  its  cutting  edge 
parallel  to  the  axis  of  the  thigh  down  to  the  bone,  at  a  point  about  one 
and  a-half  inches  above  the  external  tuberosity.  While  it  is  held 
firmly  in  position  against  the  bone  it  is  turned  to  the  transverse  direc- 
tion and  is  then  driven  through  the  cortex.  When  it  enters  the 
medullary  canal,  as  is  made  evident  by  the  lessened  resistance,  it  is 
partly  withdrawn  and  moved  slightly  to  one  side  and  the  other  and 
driven  through  the  cortical  substance  until  by  gentle  force  the  bone 
may  be  fractured.  The  osteotome  is  then  withdrawn,  the  minute 
wound  is  covered  with  a  pad  of  dry  gauze,  or  if  the  oozing  is  profuse 
it  may  be  closed  with  a  catgut  suture.  The  deformity  is  then  slightly 
over-corrected  and  a  plaster  spica  bandage  is  applied.  If  the  de- 
formity is  double  both  limbs  are  operated  upon  at  the  same  sitting. 

The  plaster  bandage  is  continued  for  from  four  to  six  weeks  and  it 
is  then  usually  supplemented  by  a  brace  which  may  be  worn  with  ad- 


422  DEFORMITIES  OF  BONES  OF  LOWER  EXTREMITY. 

vantage  for  several  months,  because  of  the  laxity  of  the  ligaments  of 
the  knee  joint  which  is  usually  present  in  extreme  deformity  of  rha- 
chitic  origin.  In  less  marked  cases,  the  support  is  unnecessary.  Mas- 
sage and  exercises  during  the  stage  of  recovery  should  be  employed  if 
possible. 

In  some  instances  the  osteotomy  of  the  femur  may  be  performed 
from  the  inner  side  at  the  same  level  more  conveniently,  especially  if 
the  deformity  is  extreme. 

Incomplete  osteotomy  and  fracture  in  the  manner  described  has  been 
employed  at  the  Hospital  for  Ruptured  and  Crippled  in  a  very  large 
number  of  cases  without  a  single  unfavorable  result.  The  discomfort 
is  insignificant  and  confinement  to  the  bed  after  the  third  day  is  un- 
necessary. 

Cuneiform  Osteotomy. — In  the  more  extreme  cases  of  general 
rhachitic  deformity  of  the  lower  extremity  in  which  the  tibia  is  im- 
plicated, it  is  sometimes  necessary  to  remove  a  cuneiform  section  of 
bone  from  the  inner  side  of  the  tibia  just  below  the  epiphysis  in  order 
to  straighten  the  leg  completely.     In  such  cases  it  is  better  to  perform 

Fig.  296. 


The  Grattau  osteoclast. 


the  second  operation  at  a  later  time  in  order  that  the  effect  of  the  fem- 
oral osteotomy  may  be  observed.  In  exceptional  cases  the  deformity 
may  be  practically  confined  to  the  tibia;  in  such  instances  it  should  be 
corrected  by  a  primary  cuneiform  osteotomy. 

Osteoclasis. — Osteoclasis,  by  means  of  the  Grattan  osteoclast,  is  an 
effective  operation.  With  this  instrument  the  bone  may  be  broken 
above  the  condyles  at  the  desired  point,  but  the  force  required  is  con- 
siderable and  it  would  seem  that  there  might  be  danger  of  separating 
the  epiphysis  or  otherwise  injuring  the  joint,  a  danger  that  may  be 
avoided  by  osteotomy. 

The  adolescent  type  of  genu  valgum  is  not  often  extreme.    As  a  rule, 


OPERATIVE  TREATMENT.  423 

the  deformity  of  the  bone  is  of  comparatively  short  duration,  and  it  is 
accompanied  by  considerable  laxity  of  ligaments.  In  the  more  chronic 
cases  the  osteotomy  above  the  condyles  may  be  performed  in  the 
manner  described,  but  in  Berlin  and  Vienna  where  the  deformity  is 
more  common  than  in  New  York,  other  procedures  are  often  employed. 

Wollf's  Treatment. — One  method  is  that  of  Wollf,  who  by 
means  of  the  "  Etappen  Verband  "  gradually  corrects  the  deformity. 

The  patient  is  anaesthetized  and  the  limb  having  been  carefully  pro- 
tected with  cotton,  particularly  so  about  the  malleoli,  the  patella  and 
the  inner  condyle,  is  enveloped  in  a  firm  plaster  bandage  reaching  from 
the  malleoli  to  the  pubes.  When  the  plaster  begins  to  harden  one 
assistant  steadies  the  pelvis,  another  holds  the  inner  condyle,  while  the 
operator  draws  the  leg  inward  with  moderate  but  persistent  force 
against  the  fulcrum  formed  by  the  hand  of  the  second  assistant  and 
holds  it  firmly  in  the  partly  corrected  position  until  the  bandage  is 
firm.  About  three  days  later  a  wedge-shaped  section  of  the  bandage 
about  one  inch  in  width  is  removed  from  the  part  that  covers  the  inner 
half  of  the  knee,  the  outer  half  of  the  bandage  being  simply  divided. 
The  leg  is  then  forced  inward  until  the  two  sections  are  again  brought 
into  contact.  The  position  is  retained  by  an  additional  plaster  bandage 
about  the  weakened  part.  This  procedure  is  repeated  at  intervals  until 
the  leg  is  completely  straightened,  a  result  that  is  often  accomplished 
in  two  weeks.  No  anaesthetic  is  required  for  the  secondary  corrections. 
When  the  deformity  has  been  corrected  the  patient  is  allowed  to 
walk  about,  and  for  convenience  the  plaster  bandage  is  divided  into  a 
thigh  and  leg  part  which  are  attached  by  lateral  joints  incorporated  in 
its  substance  so  that  motion  is  allowed.  This  apparatus  mast  be  worn 
for  several  months  and  is  of  course  to  be  supplemented  by  massage  and 
exercises. 

LoRENz's  Operation. — Another  means  of  correction  of  deformity 
without  open  operation  is  that  employed  by  Lorenz,  what  he  calls  "  In- 
traarticulare  modelirerende  redressement."  In  this  operation  the  de- 
formity is  reduced  under  anaesthesia  at  one  sitting  by  the  gradual  ap- 
plication of  force  by  means  of  the  Lorenz  osteoclast.  The  reduction 
depends  partly  upon  the  stretching  of  the  external  ligaments  and  partly 
upon  the  actual  bending  of  the  diaphysis  of  the  bone,  as  in  the  Wollf 
method. 

When  the  leg  has  been  straightened,  or  somewhat  over-corrected 
even,  a  long  plaster  bandage  is  applied  which  is  worn  for  six  weeks 
and  is  then  replaced  by  a  jointed  walking  brace  to  be  worn  for  about 
a  year.  The  operation  is  not  attended  by  severe  pain  and  the  patient 
is  usually  allowed  to  walk  about  in  a  few  days. 

Genu  Varum. 

Synonym.^Bow  Leg. 

The  term  bow  legs  includes,  in  its  popular  sense,  all  the  distortions 
that  cause  a  separation  of  the  knees  when  the  ankles  are  in  contact  with 
one  another.     But,  strictly  speaking,  genu  varum  is  the  reverse  of  genu 


424 


DEFORMITIES  OF  BONES  OF  LOWER  EXTREMITY. 


valgum,  that  is,  the  cause  of  the  distortion  is  at  or  near  the  knee  joint, 
while  bow  leg,  as  the  name  implies,  is  a  simple  bowing  of  the  tibia  and 
fibula,  as  a  rule  near  the  ankle  joint.  (Fig.  303.)  In  true  genu  varum  a 
line  dropped  from  the  head  of  the  femur  falls  inside  the  knee  (Fig.  297), 
the  inner  condyle  of  the  femur  and  the  inner  tuberosity  of  the  tibia  bear 
the  greater  part  of  the  weight,  the  outer  condyle  is  on  the  same  level  or 

somewhat    lower    than    the 
Fig.  297.  internal  and  the  outer  tuber- 

osity   of  the    tibia    may  be 


Fig.  298. 


The  genu  varum  type  of  bow  legs,  showiug 
the  outward  rotation  of  the  femora. 


The  same  patieut,  showiug  the  separa- 
tion of  the  malleoli  when  the  knees  are  in 
contact. 


somewhat  higher  than  the  internal.  The  femur  is  abducted  and 
rotated  outward,  the  tibia  is  rotated  inward.  These  changes,  it  will  be 
noted,  are  the  reverse  of  those  found  in  genu  valgum.  As  has.  been 
stated,  the  deformity  of  genu  valgum  disappears  when  the  legs  are 
flexed,  and  in  genu  varum  if  the  legs  are  flexed  and  the  knees  are 
placed  in  contact  with  one  another  the  malleoli  may  be  actually  sepa- 
rated, simulating  the  deformity  of  knock  knee.     (Fig.  298.)     This  is 


SYMPTOMS. 


425 


explained  by  the  inward  rotation  of  the  femora,  necessitated  by  placing 
the  kniees  in  contact  with  one  another. 

'*'  In  genu  varum  the  distortion  of  the  bones  is  not  as  strictly  confined 
to  the  neighborhood  of  the  knee  joint  as  in  genu  valgum,  and  in  simple 
bow  leg  there  is  almost  always  a  certain  amount  of  distortion  at  the 
knee,  dependent,  in  part,  upon  laxity  of  the  ligaments.  It  is  proper 
therefore  to  use  the  two  terms  synonymously,  although  one  must  dis- 
tinguish a  decided  difference  between  the  genu-varum  type  in  which 
the  deformity  is  greatest  at  the  knee,  and  which  is  accompanied  as  a 
rule  by  marked  laxity  of  the  ligaments  (Fig.  299),  and  the  bow-leg 

Fig.  299. 


Genu  varum  of  rhachitic  origin  in  an  adult.    Treated  successfully  by  osteotomy. 

type  in  which  the  deformity  may  be  strictly  confined  to  the  lower  third 
of  the  leg.     (Fig.  303.) 

Symptoms. — As  was  said  of  genu  valgum,  the  deformity  is  the 
principal  symptom.  The  gait  is  somewhat  rolling  because  each  foot 
must  describe  a  part  of  the  arc  of  a  circle  before  reaching  the  ground  ; 
and  because  of  the  inward  rotation  of  the  tibiae  or  because  of  the  in- 
ward spiral  twist  of  the  bone  that  is  sometimes  present,  patients  often 
toe  in,  in  walking. 

Except  in  extreme  cases  the  weakness  and  awkwardness,  character- 
istic of  genu  valgum,  are  absent.     This  may  be  explained  by  the  fact 


426 


DEFORMITIES  OF  BONES  OF  LOWER   EXTREMITY. 


that  the  relation  of  the  bones  is  such  that  the  general  attitude  is  one  of 
activity,  the  weight  falling  on  the  outer  side  of  the  feet,  thus  flat  foot 
is  uncommon  as  an  accompaniment  of  bow  leg,  except  in  the  early  or 
rhachitic  type. 

Measurements. — The  full  effect  of  the  deformity  appears  only  when 
the  weight  of  the  body  is  borne,  but  for  practical  purposes  the  tracing 

of  the  extended  legs  is  the  best  method 
Fig.  300.  of  recording  the  fixed  deformity.    In  true 

genu  varum  the  deformity  is  greatest  at 
the  knee  and  in  the  distortion  the  apposed 
surfaces  of  the  femur  and  of  the  tibia 
participate. 

In  simple  bow  leg  the  deformity  may 
be  confined  to  the  tibia,  which,  in  addition 
to  the  outward  bowing,  may  be  twisted 
inward  somewhat  upon  its  long  axis. 

Genu  varum  may  be  unilateral  or  it 
may  be  combined  with  genu  valgum  of 
its  fellow  (Fig.  291),  and  occasionally 
slight  knock  knee  and  slight  bow  leg 
may  be  present  in  the  same  limb. 

Treatment.  Expectant  Treatment. — 
The  slighter  cases  of  bow  leg  in  early 
childhood  may  be  treated  by  manipula- 
tion. The  leg,  grasped  firmly  at  the 
ankle  and  at  the  knee,  is  straightened 
with  a  certain  amount  of  force,  over  and 
over  again.  Gradual  correction  by  this 
means  may  be  hastened  by  making  the 
sole  of  the  shoe  slightly  thicker  on  the 
outer  border.  This  aids,  also,  in  correct- 
ing the  secondary  pigeon  toe,  but  if  the 
foot  is  weak,  as  it  usually  is  in  rhachitic  cases,  this  method  should  not 
be  employed,  as  it  might  induce  flat  foot. 

Treatment  by  Braces. — If  the  deformity  is  more  extreme,  or  if  im- 
provement does  not  follow  expectant  treatment,  apparatus  should  be 
employed.  If  the  distortion  is  confined  to  the  lower  third  of  the  tibia, 
a  Knight  brace  may  be  used.  It  consists  of  two  uprights  attached  to 
a  foot  plate,  the  inner  bar  is  provided  with  a  pad  at  its  upper  end  for 
pressure  on  the  internal  condyle  of  the  femur.  The  outer  bar  reaches 
to  the  head  of  the  fibula  and  the  two  are  joined  by  a  calf  band.  When 
applied  the  leg  is  drawn  toward  the  inner  upright  by  means  of  a  lacing, 
which  passes  about  it  within  the  outer  bar.  When  the  lacing  is  made 
fast,  the  outer  bar  is  bent  toward  the  leg  and  thus  it  aids  somewhat  in 
supporting  it  in  an  improved  position.  The  foot  plate  may  be  dis- 
pensed with  and  the  brace  may  be  attached  to  the  shoe  and  even  the 
outer  bar  may  be  removed,  leaving  only  the  upright,  which  is  held  in 
position  by  the  lacing.    The  apparatus,  then,  has  the  appearance  of  a 


Long  braces  for  genu  varum 

FORD  AND  LOVETT. 


(Brad- 


OPERATIVE  TREATMENT.  427 

gaiter  and  has  the  advantage  of  being  inconspicuous,  although  some- 
what l6ss  effective  than  the  Knight  brace.  By  this  apparatus,  combined 
mth  vigorous  manipulation,  the  deformity  may  be  corrected,  in  young 
children,  in  about  six  months. 

If  the  outward  bowing  of  the  knee  is  marked,  another  form  of  ap- 
paratus will  be  necessary,  and  its  effectiveness  will  be  much  increased 
if  there  is  no  joint  at  the  knee.  The  outer  bar,  shaped  to  the  contour  of 
the  leg,  is  attached  above  to  a  pelvic  band  and  below  to  a  foot  plate,  as 
is  the  short  brace.  An  inner  straight  bar  extends  to  the  upper  third 
of  the  thigh  and  is  attached  to  the  outer  bar  by  a  thigh  band.  This 
inner  upright  is  provided  with  a  lacing  of  leather  or  canvas,  similar  to 
that  of  the  short  brace,  which  surrounds  the  knee  and  upper  part  of 
the  leg,  and  thus  draws  it  toward  an  improved  position.  The  outer 
bar  is  then  bent  slightly  inward  and  serves  as  an  additional  support. 
Another  form  of  apparatus  consists  of  a  single  upright,  attached  to  the 
shoe  and  extending  upward  as  high  as  possible  on  the  inner  aspect  of 
the  thigh.  At  its  upper  extremity  a  pressure  pad  is  placed  and  the 
knee  is  drawn  toward  it  by  means  of  straps  or  bandages. 

An  improved  brace  of  this  kind  is  that  in  use  at  the  Boston  Children's 
Hospital,  in  which  the  upper  part  of  the  upright  is  curved  upward  and 
outward  just  below  the  groin,  to  a  point  on  a  level  with,  and  behind, 
the  trochanter,  and  is  attached  to  its  fellow  by  means  of  a  strap  passing 
across  the  buttocks  so  that  the  feet  may  be  somewhat  rotated  outward 
if  necessary.     (Fig.  300.) 

Operative  Treatment. — In  children  more  than  five  years  of  age,  and 
in  cases  of  the  more  extreme  type  at  an  earlier  age,  or  when  the  op- 
portunity for  mechanical  treatment  is  lacking,  immediate  correction 
of  the  deformity  is  indicated.  Either  osteoclasis  or  osteotomy  may  be 
employed,  and  in  some  instances  manual  force  is  sufficient  for  the 
correction  of  the  deformity.  There  is  but  little  choice  between  the 
methods.  Osteoclasis  is  somewhat  safer  possibly,  and  is  to  be  pre- 
ferred for  the  younger  patients  who  may  be  treated  as  out-patients. 

At  the  Hospital  for  Ruptured  and  Crippled,  osteotomy  is  almost 
invariably  performed.  The  small  osteotome  is  inserted  on  the  inner 
aspect  of  the  tibia  at  the  point  of  greatest  deformity,  and  when  the 
bone  has  been  sufficiently  weakened,  the  fracture  is  completed  by 
manual  force.  The  fibula  may  be  broken  at  the  same  time,  or,  as  is 
usually  the  case,  it  may  be  simply  bent  outward.  The  deformity  is 
corrected  or  slightly  over-corrected  and  a  well-fitting  plaster  bandage, 
including  the  foot  and  extending  to  the  trochanter,  is  applied. 

The  patient  usually  remains  in  bed  for  a  few  days,  he  is  then  dressed 
and  if  he  so  desires  is  allowed  to  stand.  Almost  no  pain  or  discom- 
fort follows  the  operation  and  in  fact,  in  properly  selected  cases,  it  is 
not  only  free  from  danger,  but  it  has  a  very  decided  advantage  over 
the  simple  mechanical  treatment.  If  the  child  is  in  good  condition, 
and  if  the  deformity  is  slightly  over-corrected  at  the  time  of  operation, 
apparatus  will  not  be  required  in  the  after-treatment ;  but  in  many 
instances  some  form  of  support  is  indicated,  usually  because  slight 


428 


DEFORMITIES  OF  BONES  OF  LOWER  EXTREMITY. 


deformity,  due  to  laxity  of  ligaments  or  to  deformity  of  the  femur, 
appears  when  the  weight  of  the  body  falls  upon  the  legs. 

It"  has  been  stated  that  the  deformity  of  bow  leg  depends  in  part 

upon  a  deformity  of  the  femur  as 
Fig.  301.  well  as  of  the  tibia.     As  a  rule, 

p-_-^— ^j.^----,  the  correction  of  the  greater  de- 

j  X,  formity  of  the  tibia  will  be  suffi- 

cient, but  in  more  extreme  cases  a 
secondary  osteotomy  above  the 
condyles  will  be  necessary.  This 
may  be  performed  simultaneously 
with  that  on  the  tibia,  but  it  is 
better  to  defer  it  until  the  effect 
of  the  primary  operation  has  been 
observed. 

Anterior  Bow  Leg. 

Synonym.  —  Anterior  Curva- 
ture of  the  Tibia. 
Anterior  bow  legs.  Botli  bow  legs  and  kuock  kuecs 

are  often  seen  in  children  who  pre- 
sent no  signs  of  general  rhachitis,  but  anterior  bowing  of  the  legs  is 
almost  always  combined  with  general  rhachitic  distortions  of  the  lower 
extremity,  most  often  with  knock  knees ;  these  in  turn  are  caused  by 
marked  distortion  of  the  femora  which  may  be  bent  forward  and  out- 


FiG.  302. 


Long  anterior  curvature  of  the  tibia  and  flat  foot. 


GENERAL  BHACHITIC  DISTORTIONS. 


429 


ward  above,  and  inward  at  their  lower  extremities,  "  corkscrew  de- 
formity." In  anterior  bow  legs  the  tibise  are  usually  flattened  from 
side  to  side,  curved  inward  or  outward  and  bent  forward,  the  project- 
ing crests  presenting  sharply  beneath  the  skin.  mgHji"^ ^ 

Symptoms. — The  effect  of  the  anterior  bowing  is  to  throw  the  weight 
forward  upon  the  foot,  thus  the  heels  appear  abnormally  long  and  promi- 
nent,   and    the    patient 

seems  to  sink  forward  at  Fig.  303. 

each  step.  (Fig.  303.) 
The  knees  are  usually 
somewhat  flexed,  partly 
as  the  effect  of  knock 
knee  with  which  the  de- 
formity is  usually  com- 
bined, and  the  feet  are, 
as  a  rule,  flat.  As  has 
been  stated,  anterior  bow- 
ing is  almost  never  seen 
as  an  independent  defor- 
mity unless  it  is  a  relic  of 
the  more  general  distor- 
tion which  has  been 
"  outgrown." 

Treatment. — Anterior 
curvature  of  the  tibia 
must,  as  a  rule,  be 
treated  by  operation. 
After  complete  division 
of  the  tibia  and  fibula, 
the  deformity  may  be 
overcome  by  forcing  the 
bones  directly  backward. 
In  certain  instances  te- 
notomy of  the  ten  do 
Achillis  may  be  required. 
Cuneiform  osteotomy  of 
the    tibia    permits    more 

perfect  correction,  but  the  final  result  is  equally  good  after  simple 
osteotomy. 

General  Rhachitic  Distortions. 

General  rhachitic  distortions  have  been  mentioned  in  connection  with 
knock  knee,  and  with  anterior  bowleg.  A  more  extended  description 
is  hardly  necessary.  The  deformities  are  usually  of  the  knock-knee 
type,  and  they  may  be  treated  on  the  same  general  plan  that  has  been 
outlined  in  the  description  of  the  less  extreme  distortions. 


Bhachitic  anterior  bow  legs. 


CHAPTER    XVI. 
DEFORMITIES   OF  THE   UPPER   EXTREMITY. 

Congenital  Dislocation  of  the  Shoulder. 

This  may  occur  in  two  forms,  one  in  which  there  is  actual  mis- 
placement before  birth,  and  the  other  in  which  a  dislocation  is  caused 
by  violence  at  birth.  In  either  case  the  displacement  is  almost  always 
backward  upon  the  dorsum  of  the  scapula  (subspinous).  Thus  the 
arm  is  abducted  and  rotated  inward  and  the  head  of  the  displaced 
bone  may  be  felt  in  its  abnormal  position.  Cases  of  congenital  dis- 
placement in  other  directions  are  recorded,  but  these  are  so  unusual 
as  to  be  of  little  practical  importance.^ 

True  primary  displacement  of  either  variety  is  rare.  Many  of  the 
reported  cases  were  apparently  subluxations  secondary  to  the  relaxa- 
tion of  the  capsule  of  the  joint  and  to  the  muscular  atrophy  caused  by 
anterior  poliomyelitis,  or  more  often  to  the  habitual  malposition  due 
to  obstetrical  paralysis.     (Fig.  305.) 

Treatment. — The  only  treatment  of  a  dislocation  is  replacement  of 
the  displaced  bone,  if  it  be  possible.  If  the  displacement  wer«  dis- 
covered in  infancy,  it  might  be  possible  to  reduce  it  by  manipulation, 
especially  if  it  were  of  traumatic  origin.  As  a  rule,  however,  the 
cases  are  not  seen  until  later  childhood  when  the  accommodative 
changes  are  so  great  as  to  necessitate  the  open  operation. 

Phelps,  of  New  York,  has  reported  several  cases  of  congenital 
dislocation  of  the  shoulder,  caused  apparently  by  injury  at  birth,  as 
most  of  them  were  accompanied  by  paralysis.  In  the  first  case  (a 
boy  eight  years  of  age)  the  joint  was  opened  by  a  posterior  incision 
along  the  border  of  the  deltoid  muscle.  The  head  of  the  scapula  was 
found  to  be  atrophied  and  the  posterior  margin  of  the  glenoid  cav'ity 
broken  away.  This,  together  with  the  contraction  of  the  tissues  on 
the  anterior  aspect  of  the  joint,  made  it  necessary  to  cut  away  a  part 
of  the  head  of  the  bone  in  order  to  replace  it.  The  secondary 
articulating  surface  on  the  scapula  was  excised  and  the  redundant 
capsule  was  removed.  The  immediate  result  of  the  operation  was 
very  favorable.  Phelps  states  that  he  has  operated  on  two  similar 
cases,  but  a  final  report  of  the  results  has  not  been  presented." 

It  would  seem,  however,  that  as  in  a  posterior  displacement  the  con- 
tracted tissues  must  be  tliose  in  front  of  the  joint,  an  anterior  rather 
than  a  posterior  incision,  would  be  preferable.     In  any  event  prolonged 

'  Scudder,  Am.  Jour.  Med.  Sci.,  February,  1898. 
2  Trans.  Am.  Orth.  Ass'n,  Vol.  VIIl. 


OBSTETRICAL  PARALYSIS. 


431 


Fig.  304. 


forcible  manual  stretching  of  the  contracted  parts  in  the  manner  de- 
scribed in  the  treatment  of  congenital  dislocation  of  the  hip  should 
precede  the  opening  of  the  joint.  By  this  means  the  writer  has  re- 
duced the  displacement  easily  in  two  cases  in  early  childhood. 

Obstetrical  Paralysis. 

Partial  or  complete  paralysis  of  the  muscles  of  the  arm  may  be  a  re- 
sult of  difficult  or  protracted  labor.  This  may  be  due  to  direct  injury 
of  the  brachial  plexus  by  the  forceps,  but  most  often  it  is  caused  by 
traction  on  the  body  or  the  head 
and  by  violent  twists  of  the  neck 
during  delivery.  The  muscles  most 
often  paralyzed  are  those  supplied 
principally  by  the  fifth  and  sixth  cer- 
vical roots  of  the  plexus,  the  deltoid, 
the  biceps,  and  the  supinators  of  the 
forearm.^  Thus  in  most  instances 
the  arm  hangs  in  an  attitude  of  slight 
abduction  and  exaggerated  prona- 
tion. (Fig.  304.)  If  the  attitude 
is  allowed  to  persist  and  if  the 
paralysis  is  permanent,  t*he  head 
of  the  humerus  rotated  backward 
beneath  the  atrophied  deltoid  mus- 
cle and  held  in  the  abnormal  atti- 
tude by  accommodative  changes  in 
the  capsule  and  surrounding  parts, 
simulates  very  closely  in  later  years 
the  true  congenital  dislocation  of  the 
shoulder.     (Fig.  305.) 

Whether  cases  reported  as  con- 
genital displacement  of  the  shoulder 
are  secondary  to  paralysis  or  not,  it 
is  evident  that  all  cases  of  obstet- 
rical paralysis  should  be  carefully 
examined  with  regard  to  a  compli- 
cating dislocation,  and  that  secondary  deformity  caused  by  paralysis 
should  be  prevented. 

Treatment. — During  the  first  month  after  birth,  the  shoulder  of 
the  paralyzed  arm  is  often  somewhat  swollen  and  motion  may  cause 
pain.  In  such  cases  rest  is  indicated.  The  arm  should  be  placed 
against  the  side,  and  the  hand,  with  the  fingers  extended,  should  be 
supported  on  the  chest  beneath  the  clothing.  When  the  primary  sen- 
sitiveness has  subsided,  each  of  the  joints  of  the  extremity  should 
be  moved  systematically  to  the  limits  of  the  normal  range  of  motion 
several  times  in  the  day.  Particular  care  should  be  exercised  in 
supinating  the  forearm  to  its  full  limit  and  extending  the  wrist  and 
'  Thomas,  Johns  Hopkins  Hosp.  Bulletin,  Nov.,  1900. 


Obstetrical  jjaralysis.    Characteristic  attitude. 


432 


DEFORMITIES  OF  THE  UPPER  EXTREMITY. 


fingers,  if  they  are  involved  in  the  paralysis.  The  muscles  should  be 
massaged  and  the  arm  should  be  supported  by  a  sling,  or  otherwise, 
in  proper  position.  Recovery  may  be  complete,  although  it  is  often 
delayed  for  many  months.  As  a  rule,  traces  of  the  injury  are  evident 
in  atrophy  of  certain  muscles,  particularly  of  the  deltoid,  and  a  certain 
weakness  of  the  arm  persists,  even  though  no  paralysis  remains. 

In  many  instances  recovery  is  but  partial,  the  arm  is  weak,  certain 
muscles  are  paralyzed,  and  there  is  much  restriction  of  movement  at 

the  shoulder.     The  growth  of 
Fig.  305.  the  member  is  retarded  and  the 

attitude  simulates  that  of  pos- 
terior dislocation,  as  has  been 
stated.     Even   in    such    cases 


massage    and 
training    will 
the   functional 
disabled  part. 


exercises    and 

often    improve 

ability  of  the 


Recurrent  Dislocation  of 
the  Shoulder. 

Recurrent  dislocation  of  the 
shoulder  is  usually  a  sequel  to 
traumatic  dislocation.  The 
cause  of  the  instability  is  usu- 
ally laxity  of  the  capsular  lig- 
ament and  weakness  of  the 
supporting  muscles,  the  result, 
it  may  be,  of  too  early  use  of 
the  arm  after  the  accident. 
In  rare  instances  greater  de- 
rangement of  the  joint,  caused 
by  fracture  of  one  or  other  of 
the  articulating  surfaces,  rup- 
ture or  displacement  of  liga- 
ments or  muscles,  or  perma- 
nent paralysis  of  the  deltoid 
muscle  may  be  present. 

The  displacement,  which 
may  be  partial  or  complete,  recurs  at  intervals  and  is  a  very  serious 
disability. 

Treatment. — If  the  patient  is  seen  immediately  after  a  displacement 
and  if  the  dislocation  has  recurred  but  a  few  times  and  at  long  inter- 
vals, it  may  be  inferred  that  the  disability  is  the  result  of  simple  laxity 
of  the  capsule  and  of  muscular  weakness.  In  such  cases  a  period  of 
fixation  followed  by  massage  and  exercise  of  the  atrophied  muscles  may 
result  in  cure.  The  patient  should  be  carefully  questioned  as  to  the  par- 
ticular movements  of  the  arm  that  are  likely  to  cause  the  displacement, 


Obstetrical  paralysis  iu  adolesceuee. 


CUBITUS  VALGUS,    CUBITUS   VARUS.  433 

which  is,  as  a  rule,  forward  beneath  the  coracoid  process.  Most  often 
elevation  and  abduction  seem  to  be  the  exciting  causes,  and  these  mo- 
tions should  be  restrained.  A  simple  and  often  an  eifective  means  of 
treatment,  is  the  application  of  a  shoulder  cap  of  canvas  that  fits  closely 
about  the  shoulder  and  upper  arm.  This  is  held  in  place  by  bands 
crossing  the  body  and  buckled  beneath  the  other  arm  ;  from  the  lower 
border  of  the  cap  one  or  more  bands  pass  downward  and  are  attached 
with  the  braces  to  the  trousers,  so  that  elevation  of  the  arm  is  re- 
strained, before  the  point  of  instability  is  reached. 

Operative  Treatment. — If  these  milder  measures  are  ineffective  an  op- 
eration to  reduce  the  size  of  the  lax  capsule  may  be  performed  according 
to  the  method  employed  by  Burrell.  The  arm  being  slightly  abducted, 
an  incision  is  made  from  the  coracoid  process  downward  and  outward 
along  the  line  of  the  cephalic  vein  to  a  point  below  the  upper  border  of 
the  tendinous  insertion  of  the  pectoralis  major.  The  deltoid  and  the 
pectoralis  major  are  separated,  exposing  in  the  upper  border  of  the 
wound  the  coraco-brachialis,  and  in  the  lower  angle  the  upper  part  of  the 
insertion  of  the  pectoralis  major.  The  upper  three-fourths  of  this  in- 
sertion is  divided  in  order  to  expose  the  head  and  neck  of  the  bone. 
The  humerus  is  then  rotated  outward  and  a  portion  of  the  insertion  of 
the  subscapularis  muscle,  stretched  over  the  head  of  the  humerus,  is  di- 
vided.    The  capsule  is  thus  laid  bare. 

In  Burrell' s  second  case  a  portion  of  the  anterior  wall  of  the  capsule 
three-eighths  of  an  inch  wide  and  three-fourths  of  an  inch  long  was 
excised,  and  the  wound  was  closed  with  sutures.  The  incised  muscles 
fell  into  apposition  when  the  arm  was  fixed  to  the  side.  Burrell  oper- 
ated on  two  patients  by  this  method  with  perfect  success. 

Similar  operations  in  which  the  lax  capsule  was  overlapped  and 
sutured  without  opening  it,  have  been  performed,  by  Ricard  in  1892 
and  by  Steinthal  in  1895.^ 

Congenital  Deformities  of  the  Elbow. 

Congenital  displacement  of  the  ulna  is  one  of  the  rarest  of  deform- 
ities. The  displacement  is  usually  incomplete,  and  it  is  associated  with 
laxity  of  the  ligaments. 

Congenital  displacement  of  the  radius  is  much  more  common. 
Thirty  cases  collected  from  the  literature  have  been  reported  by  Bon- 
nenburg.^  The  symptoms  are  similar  to  those  of  the  traumatic  dislo- 
cation. The  deformity  is  often  overlooked  in  childhood,  and  as  it 
causes  no  great  disability,  treatment  is  not  usually  desired.  In  several 
instances  the  head  of  the  radius  has  been  removed  with  a  favorable  ef- 
fect in  increasing  the  range  of  supination. 

Cubitus  Valgus,  Cubitus  Varus. 

Cubitus  valgus,  in  which  the  forearm  is  abducted  at  the  elbow  and  cu- 
bitus varus,  in  which  it  is  inclined  in  the  other  direction,  are  occasion- 

*  Burrell  and  Lovett,  Am.  Jour.  Med.  Sci.,  Aug.,  1897. 
2Zeits.  fiir  Orth.  Chir.,  Bd.  2. 
2io 


434  DEFORMITIES  OF  THE   UPPER  EXTREMITY. 

ally  seen  as  congenital  deformities.     They  are,  in  most  instances,  asso- 
ciated with  laxity  of  the  ligaments. 

Similar  deformities  are  not  uncommon  during  the  progessive  stage  of 
rhachitis,  but  they  usually  disappear  when  the  erect  attitude  is  assumed 
and  when  the  arms  are  relieved  of  the  strain  of  supporting  the  body  in 
the  sitting  posture.  What  may  be  called  normal  cubitus  valgus,  is 
common  among  women,  and  in  certain  instances  it  may  be  exaggerated 
to  deformity.  Acquired  cubitus  varus  is  usually  the  result  of  direct 
injury. 

Subluxation  of  the  Wrist. 

A  peculiar  displacement  of  the  hand  forward  and  to  the  radial  or 
ulnar  side,  described  by  Madelung  ^  as  "  spontaneous  subluxation,"  is 
sometimes  seen  in  young  subjects  whose  occupation  may  require  con- 
stant use  of  the  flexors  of  the  hand  and  fingers.  In  these  cases  the 
lower  extremities  of  the  bones  of  the  arm  project  on  the  dorsal  surface, 
the  flexor  tendons  are  prominent  on  the  palmar  aspect  and  limit  the 
range  of  extension  of  the  hand,  the  wrist  may  be  slightly  enlarged  and 
the  ligaments  seem  to  be  relaxed.  The  symptoms,  aside  from  the  de- 
formity, are  weakness  and  sensations  of  discomfort  about  the  dorsum 
of  the  wrist. 

Etiology. — The  predisposing  causes  of  the  affection  are,  apparently, 
relaxation  of  the  ligaments  and,  possibly,  slight  preexisting  rhachitic 
deformity  of  the  same  character.  The  exciting  causes  are  occupation 
or  injury.  In  some  instances  there  is  a  slight  forward  bending  of  the 
lower  extremity  of  the  radius,  due,  apparently,  to  irregularity  in  growth 
at  the  epiphyseal  junction. 

Treatment. — The  treatment  is  rest,  massage,  forcible  manipulation 
in  the  direction  of  extension  and  a  support  of  leather  or  other  material 
to  hold  the  hand  in  the  extended  position  until  the  tendency  to  defor- 
mity is  checked. 

Congenital  Deformities  at  the  Wrist. 

Simple  congenital  dislocation  of  the  wrist  is  extremely  rare.  Dis- 
placement of  the  wrist  and  hand  is  usually  associated  with  defective 
development  of  the  bones  of  the  arm,  and  the  deformity  is  usually 
classed  as  club  hand. 

Club  Hand. 

Congenital  distortions  of  the  hand  may  be  divided  into  four  primary 
varieties,  according  to  the  direction  in  which  the  hand  is'  turned,  viz.: 

1.  Forward  or  palmar. 

2.  Backward  or  dorsal. 

3.  Lateral  to  the  radial  side — radial. 

4.  Lateral  to  the  ulnar  side — ulnar. 

Lateral  and  antero-posterior  distortions  occur  also  in  combination. 
■     Etiology. — There  are  two  distinct  varieties  of  club  hand  : 

1  Archiv  f.  Klin.  Chir.,  Bd.  23. 


CLUB  HAND. 


435 


1.  In  which  there  is  simple  distortion  caused  apparently  by  ab- 
normal fixation  and  pressure  in  utero. 

2.  In  which  the  deformity  is  associated  with  defective  develop- 
ment of  the  radius  or  ulna  and  often  with  congenital  abnormalities  of 
other  parts. 

In  the  palmar  and  dorsal  distortions  the  bones  of  the  arm  are  usually 
normal.  The  lateral  deviations  of  the  hand  are  often  caused  by  de- 
fective formation  of  the  radius  or  ulna,  and  thus  they  correspond  to 
talipes  due  to  absence  of  the  tibia  or  fibula. 

According  to  Hoffa/  39  cases  of  the  former  and  but  6  of  the  latter 
are  recorded ;  in  but  one  case  was  there  entire  absence  of  the  ulna. 

Fro.  306. 


Club  hands  and  club  feet. 

Of  the  39  cases  of  radial  club  hand  19  were  of  both  sides.  These  sta- 
tistics, however,  by  no  means  represent  the  relative  frequency  of  the 
deformity.  From  the  writer's  observation  it  would  appear  that  radial 
club  hand  is  nearly  as  common  as  the  deformity  of  the  foot  caused  by 
absence  of  the  fibula,  of  which,  according  to  Potel,  there  are  200  re- 
corded cases.  The  ulnar  form  of  club  hand  is  less  frequent  even  than 
the  deformity  due  to  defective  formation  of  the  tibia. 

The  most  important  form  of  club  hand  is,  then,  that  due  to  absence 
or  to  defective  formation  of  the  radius.  As  in  talipes  valgus  due  to 
absence  of  the  fibula,  the  tibia  is  short  and  often  bent  sharply  forward, 
so  in  this  form  of  club  hand  ihe.  ulna  is  usually  short  and  bent  inward. 
The  hand  may  be  perfect  in  formation,  but  as  a  rule  the  thumb  is  ab- 

1  Lehrb.  der  Orth.  Chir.,  p.  481. 


436 


DEFORMITIES  OF  THE   UPPER  EXTREMITY. 


sent  or  rudimentary  and  other  adjoining  bones,  together  with  the  cor- 
responding ligaments  and  muscles,  may  be  absent  also.     (Fig.  307.) 

The  hand  occupies  practically  a  right-angled  relation  to  the  ulna 
and  as  this  bone  is  usually  bent  inward  as  well,  the  direction  of  the 
hand  is  often  reversed  and  is  parallel  to  the  forearm.  As  a  rule  the 
hand  is  also  somewhat  bent  forward,  so  that  the  deformity  might  be 
described  as  radio-palmar.     (Fig.  308.) 

Treatment. — In  those  forms  of  club  hand  in  which  the  structure 
is  normal  the  deformity  may  be  overcome  as  a  rule  by  manipulation, 
and  support  by  the  plaster  bandage  or  otherwise.  Massage  and  mus- 
cle training  are  required  in  the  after-treatment. 

In  slighter  cases  of  radial  club  hand,  due  to  defective  development. 

Fig.  307. 


Congenital  absence  of  radius  and  the  bones  of  the  thumb.     (Weigel.  ) 

it  may  be  possible  by  manipulation  and  tenotomy  to  replace  the  hand 
in  its  normal  position,  but  this  is  unlikely.  As  a  rule  an  operation  on 
the  ulna  will  be  necessary,  together  with  division  of  the  contracted 
tissues.  Sayre  ^  removed  a  portion  of  the  carpus  and  implanted  the 
head  of  the  ulna  at  the  point  of  resection.  McCurdy  ^  sawed  through 
the  ulna,  leaving  the  extremity  in  relation  to  the  carpus  and  sutured 
the  proximal  fragment  and  the  semi-lunar  bone  to  one  another. 
Thomson  ^  replaced  the  hand  by  subcutaneous  tenotomy  and  by  the  re- 
moval of  a  cuneiform  section  of  bone  from  the  lower  end  of  the  ulna. 
The  operation  of  splitting  the  ulna  into  an  ulnar  and  radial  portion 

'Trans.  Amer.  Orth.  Ass'n,  Vol.  YI. 
2 Ibid.,  Vol.  VIII. 
3 Ibid.,  Vol.  IX. 


WEBBED  FINGERS.  437 

aud  implanting  the  carpus  between  the  two,  has  been  performed  by 
Bard^nhauer.^  The  immediate  effect  of  the  various  operative  proce- 
dures was  favorable,  but  no  final  results  have  been  reported. 

In  any  event  some  form  of  apparatus  must  be  used  during  child- 
hood at  least,  to  support  the  hand,  whether  the  operation  has  been 
successful  or  not ;   and  at  best  the  arm 
will  be  short,  and  the  thumbless  hand  Fig.  308. 

will   be  weak    as   compared  with    the 
normal. 

Congenital  Contraction  of  the 
Fingers. 

The  most  common  form  of  congenital 
contraction  is  that  of  the  little  finger,  on 
one  or  both  hands,  which  is  semi-flexed, 
apparently,  because  of  deficiency  of  the 
skin.  In  other  instances  several  fingers 
may  be  similarly  affected. 

Treatment. — If  treatment  by  manip- 
ulation and  splinting  is  begun  early  the 
deformity  may  be  overcome  by  length- 
ening the  contracted  tissues.  In  later 
life  the  prospect  of  perfect  cure  by  any 
method  of  treatment  is  slight,  because 
of  the  strong  tendency  to  recontraction 
after  the  finger  has  been  straightened. 

Webbed  Fingers. 

In  the  most  common  form  of  this  de- 
formity two  or  more  fingers  are  joined  by 
skin  and  fibrous  tissue  to  the  first  pha- 
langeal joints,  but  sometimes  through- 
out the  entire  length  of  the  fingers. 

In  other  instances  the  web  may  be 
thicker,  containing  muscular  fibers  from 
the  apposed  parts  and,  occasionally,  the       ,,e  feTzld  det-med  forl'arrsrirs! 
bones  ol  the  two  fingers  may  be  joined  to       ^^^  '^gs.   (Gibney.) 
one  another,  even  to  the  finger  nails. 

Etiology. — The  cause  of  the  deformity  is  arrest  of  development  before 
the  fingers  have  been  separated  from  one  another,  thus  the  thumb,  which 
is  differentiated  from  the  other  parts  of  the  hand  as  early  as  the 
seventy-fifth  day  of  intra-uterine  life,  is  rarely  involved,  as  compared 
with  the  fingers  which  are  separated  from  one  another  at  a  later  period. 

Treatment. — In  all  but  the  extreme  grades  of  deformity  the  fingers 
may  be  separated  from  one  another ;  operative  treatment  being  con- 
ducted according  to  the  rules  of  plastic  surgery. 

1  Verhand.  der  deutsch.  Gesells.  fur  Chir.,  23  Kong.,  1894. 


438  DEFORMITIES  OF  THE   UPPER  EXTREMITY. 

Congenital  Displacements  of  the  Phalanges  and  Distortions 

of  the  Fingers. 

These  deformities  are  not  particularly  imconimon.  They  should  be 
treated  by  manipulation  and  by  splinting  at  as  early  a  period  as  is 
practicable.  Other  congenital  deformities  and  malformations  of  the 
hand  do  not  call  for  extended  comment. 

Trigger  Finger. 

Synonyms. — Jerking  Finger,  Snapping  Finger. 

This  affection  was  first  described  by  Nelaton  under  the  title  Doigt  a 
Ressort.  On  extending  the  closed  hand  one  finger  remains  flexed.  If 
the  flexion  is  overcome  by  greater  muscular  effort  or  by  passive  force 
the  finger  flies  back  to  complete  extension  with  a  sudden  snap  or  jerk, 
hence  the  name.  In  well-marked  cases  the  same  difiiculty  and  the 
subsequent  snap  is  experienced  in  flexing  the  finger.  The  middle  and 
ring  fingers  are  more  often  affected  but  sometimes  the  thumb  or  the 
fifth  finger  may  be  involved. 

The  patient  usually  complains  somewhat  of  stiffness  and  pain  in  the 
finger  but  the  interference  with  its  function  is  the  principal  symptom. 

Etiology. — The  usual  explanation  of  the  disability  is  interference 
with  the  motion  of  the  tendon  in  its  fibrous  sheath,  either  because  of  a 
reduction  of  its  calibre  due  to  injury  or  inflammation,  or  to  an  enlarge- 
ment or  irregularity  of  the  tendon  itself.  In  most  instances  the  obstruc- 
tion appears  to  be  in  the  neighborhood  of  the  metatarso-phalangeal  joint. 

The  duration  of  the  affection  is  indefinite. 

Treatment. — If  the  obstruction  appears  to  be  of  inflammatory  or 
traumatic  origin  it  may  be  treated  by  splinting  and  later  by  massage. 
In  confirmed  cases  the  tendon  and  the  sheath  may  be  explored  in  the 
hope  of  finding  and  removing  the  obstruction.^ 

Mallet  Finger. 

Synonym. — Drop  Finger. 

This  is  caused  usually  by  a  blow  upon  the  terminal  phalanx  which 
ruptures  or  weakens  the  attachment  of  the  extensor  tendon  at  the  base  of 
the  phalanx  so  that  it  is  habitually  flexed  to  a  right  angle  with  the  finger. 

The  treatment  must  be  by  incision  and  reattachment  of  the  tendon 
to  the  periosteum. 

Baseball  finger  (Abbe)  is  the  reverse  displacement  of  the  terminal 
phalanx  which  is  dislocated  backward,  forming  a  bayonet-like  deformity. 

If  reposition  is  impossible  open  incision  should  be  employed  to  cor- 
rect the  deformity. 

Dupuytren's  Contraction. 

Dupuytreu's  contraction  is  a  deformity  of  the  hand  caused  by  contrac- 
tion of  a  part  of  the  palmar  fascia  and  of  its  prolongations  to  one  or 

1  The  bibliography  is  hvrs'e.  More  recent  articles  are  those  of  Jamin,  Cent,  fiir  Chir., 
June  6,  1896,  who  reports  31  cases  and  A.  Necker,  Beitrage  zur  Klin.  Chir.,  Bd.  X., 
p.  469. 


DUFUYTBEN'S  CON TB ACTION.  439 

more  of  the  fingers.  The  fingers  are  flexed  as  a  consequence,  to  a 
greater  or  less  degree,  and  in  advanced  cases  they  may  be  drawn  to  close 
contact  with  the  palm.  The  ring  finger  is  most  often  primarily  affected 
but  as  a  rule  two  or  more  fingers  are  somewhat  involved  in  the  contraction. 

In  a  large  proportion  of  the  cases  both  hands  are  involved,  but  not 
as  a  rule  simultaneously,  the  contraction  beginning  in  the  second  hand 
several  years  after  the  deformity  in  the  first. 

Pathology. — The  characteristics  of  the  deformity  are  explained  by 
the  anatomy  of  the  palmar  fascia.  This  consists  of  a  strong  central 
portion,  and  two  thinner  lateral  parts  that  cover  the  muscles  of  the 
thumb  and  little  finger.  It  is  made  up  of  longitudinal  fibers  continu- 
ous with  the  tendon  of  the  palmaris  longus  and  the  annular  ligament. 
It  divides  into  four  processes  that  are  attached  to  the  digital  sheaths,  to 
the  integument  at  the  clefts  of  the  fingers  and  to  the  superficial  trans- 
verse ligament.  Prolongations  of  the  fascia  pass  along  the  lateral 
aspect  of  the  fingers  and  are  attached  to  the  periosteum  and  to  the 
tendon  sheaths  of  the  first  and  second  phalanges. 

The  cause  of  the  contraction  appears  to  be  a  chronic  plastic  inflam- 
mation of  a  part  of  the  fascia,  which  becomes  hypertrophied,  and  finally 
contracts,  drawing  the  finger  toward  the  palm  in  the  manner  described. 

Etiology. — The  etiology  is  uncertain. 

The  contraction  is  much  more  common  in  men  than  in  women  and 
it  is  practically  confined  to  middle  and  later  life.  It  is  claimed  that 
the  deformity  is  more  common  among  those  who  are  subject  to  gout  or 
rheumatism.  It  appears  also  to  be  an  hereditary  affection  in  certain 
instances.  Injury  or  irritation  of  the  palmar  tissues,  incident  to  cer- 
tain occupations,  would  seem  to  explain  the  disproportionate  liability 
of  the  sexes  to  the  affection. 

Symptoms. — The  first  symptom  is  usually  the  deformity ;  the  pa- 
tient finds  it  impossible  to  completely  extend  one  or  more  of  the 
fingers,  the  tissues  about  the  base  of  the  finger  seem  stiff,  and  when  it 
is  forcibly  extended  a  hard,  elevated  cord  may  be  felt  extending  from 
about  the  center  of  the  palm  to  the  second  phalanx,  most  prominent 
at  the  metacarpo-phalangeal  articulation. 

To  this  the  skin  is  adherent,  and  as  the  contraction  increases  it  is 
thrown  into  elevated  ridges.  Later,  other  bands  appear  if  the  con- 
traction affects,  as  it  usually  does,  other  portions  of  the  fascia.  In 
many  instances  no  pain  is  experienced  unless  the  contracted  fascia  is 
forcibly  stretched  or  is  pressed  upon.  In  other  cases  complaint  is 
made  of  neuralgic  pain  in  the  hand  and  even  in  the  arm  and  back. 
Occasionally  the  first  symptom  to  attract  attention  may  be  a  sensitive 
nodule  in  the  skin  at  the  base  of  the  finger. 

The  contraction  usually  increases  slowly  until  the  finger  that  is  most 
affected  is  drawn  to  the  palm. 

Treatment. — The  deformity  may  be  overcome  by  division  or  prefer- 
ably by  removal  of  the  contracted  bands  of  fascia.  The  finger  is  then 
supported  in  an  attitude  of  slight  flexion  until  the  circulation  is  adjusted 
to  the  new  position. 


CHAPTER    XVII. 
DISEASES  OF  THE  NERVOUS   SYSTEM. 

From  the  orthopaedic  standpoint,  only  those  diseases  that  directly  in- 
terfere with  the  function  of  locomotion  or  that  cause  deformity,  and 
for  which  local  treatment  is  of  benefit,  are  of  especial  interest.  Even 
this  limited  class  is  not  often  seen  in  the  early  or  progressive  stage 
and  it  is  rather  with  the  effects  of  a  disease  that  is  no  longer  present 
than  with  the  disease  itself  that  the  orthopaedic  surgeon  is  especially 
concerned. 

The  relative  importance  of  this  branch  of  orthopaedic  work  may  be 
illustrated  by  the  statistics  of  the  Hospital  for  Ruptured  and  Crippled. 
In  a  period  of  ten  years,  1890-1899,  forty-two  thousand  one  hundred 
and  twenty-four  new  patients  were  examined  in  the  out-patient  de- 
partment. Excluding  cases  that  cannot  properly  be  classed  as  ortho- 
paedic, thirty-eight  thousand  four  hundred  and  nineteen  remain.  In 
two  thousand  four  hundred  and  forty-one  of  these  the  nervous  system 
was  involved  (6.3  per  cent.).  Two  thousand  and  twenty-eight  of  the 
cases  were  in  young  children ;  four  hundred  and  thirteen  of  the  pa- 
tients were  more  than  fourteen  years  of  age  and  of  this  number  two 
hundred  and  sixty-six  were  adults. 

Anterior  poliomyelitis  furnished  about  75  per  cent,  of  the  total 
number.  In  20  per  cent,  the  cerebrum  was  involved  and  5  per  cent, 
were  miscellaneous  cases.  In  611  cases  treated  in  a  period  of  about 
two  years  there  were  463  cases  of  poliomyelitis,  121  cases  of  paralysis 
of  cerebral  origin,  1 6  cases  of  obstetrical  paralysis,  4  cases  of  pseudo- 
hypertrophic muscular  paralysis  and  7  miscellaneous  cases. 

These  statistics  will  explain  the  selection  of  diseases  of  the  nervous 
system  for  consideration  and  the  order  in  which  they  are  described. 

Acute  Anterior  Poliomyelitis. 

Synonym. — Infantile  Paralysis. 

Pathology. — Anterior  poliomyelitis  is  an  acute  inflammatory  process 
of  the  area  of  the  gray  matter  of  the  anterior  cornua  supplied  by  the 
anterior  spinal  arteries  involving  both  the  neuroglia  and  the  cells,  and 
resulting  in  degeneration  and  atrophy  of  the  interstitial  tissue  and  of 
the  ganglion  cells. ^ 

In  the  acute  febrile  form,  comprising  about  three-fourths  of  the 
cases,  there  is  an  actual  inflammation  ;  in  the  other  type,  in  which  there 
are  no  constitutional  evidences  of  disease,  the  symptoms  may  be  caused 
by  hemorrhage  or  by  thrombosis. 

^  Starr,  Loo  mis-Thompson,  System  of  Practical  Medicine. 


ETIOLOGY. 


441 


The  minute  changes  in  the  cord  are  characteristic  of  inflammation, 
disteiided  blood  vessels,  minute  hemorrhages,  infiltrating  leucocytes 
and  serum.  In  the  early  stage  the  motor  cells  become  cloudy  in  ap- 
pearance, later  they  are  swollen  and  lose  their  distinct  outlines.  The 
degenerative  changes  aiFect  both  the  cells  and  neuroglia  ;  the  affected 
gray  matter  shrinks  and  the  nerve  fibers  atrophy,  and  the  cord  becomes 
distinctly  smaller  at  the  seat  of  the  disease.  When  the  motor  con- 
ductivity of  the  cells  is  cut  off,  the  muscles  which  are  supplied  by  them 
are  paralyzed  and  waste  away.  The  circulation  in  the  affected  parts 
is  impaired,  contractions  and  distortions  appear  and  growth  is  retarded. 

Etiology. — The  etiology  of  the  disease  is  obscure.  Exposure  to 
heat,  sudden  chilling  of  the  body,  over-fatigue,  injury  and  the  like,  are 
thought  to  be  predisposing  causes,  while  the  direct  cause  of  the  inflam- 
matory disease  of  the  cord  is  supposed  to  be  some  form  of  infection. 

The  disease  affects  the  sexes  in  nearly  equal  numbers,  and  those  in 
perfect  health  as  often  as  those  whose  resistance  is  enfeebled.  It  some- 
times occurs  in  epidemics  and  there  are  instances  in  which  several 
members  of  the  same  family  have  been  affected,  but  usually  the  cases 
are  isolated  and  no  adequate  cause  for  the  disease  can  be  assigned. 

Age. — Acute  anterior  poliomyelitis  is  essentially  a  disease  of  infancy. 
This  is  illustrated  by  the  combined  statistics  of  several  observers  tabu- 
lated by  Starr.  ^ 


i 

CO 

i 

i 

K 

00 

3 

S 

Seeligmuller 

20 
17 
44 
21 
16 

25 
38 
92 
21 
38 

18 
15 
55 
25 

27 

1 

4 

29 

9 

9 

1 
1 
9 

17 
10 

2 
0 

2 
4 
4 

0 
0 
3 

2 

2 

0 
0 
6 

I 

0 
0 
0 
4 
4 

0 

G  albraith  

0 

Sinkler 

3 

Gowers 

0 

Starr 

3 

118 

214 

140 

52 

38 

12 

7 

14 

8 

6 

472,  01 

77  p 

3r  cen 

t.,  bef 

ore  t\ 

le  f  ou 

rth  ye 

ar. 

It  is  far  more  common  during  the  warm  months  than  at  other  sea- 
sons, as  is  illustrated  in  452  cases  tabulated  by  Starr.^ 

January 8 

February 5 

March 20 

April 9 

May 18 

June 49^ 

Ayjl'ust 116  f'^^^'  ^^'  "^^  P^^*  ^^"*-'  during  the  four 

September  ■.■.■.;■.■.  65  J       "'^"^^^'  ^""^  *^  September. 

October 42 

November 11 

December 12 

452 


'  Loomis-Thompson,  System  of  Practical  Medicine. 


^Loc.  cit. 


442 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


Distribution  of  the  Paralysis. — The  lower  extremities  are  far  more 
often  paralyzed  than  the  upper.  In  416  of  595  cases,  tabulated  by 
Starr,  the  paralysis  was  limited  to  the  lower  extremities,  as  contrasted 
with  53  cases  in  which  the  upper  extremities  were  alone  involved. 


Both  legs 9 

Eight  leg 25 

Left  leg 7 

Eight  arm 5 

Left  arm 5 

Both  arms 2 

All  extremities 5 

Arm  and  leg  same  side 1 

Arm  and  leg  opposite  sides I  2 

Trunk i  1 

Three  extremities I  0 


62 


14 
15 
27 
9 
4 
1 
2 
2 
1 
0 
0 


75 


107 

63 

62 

5 

8 

1 

35 

26 

1 

22 

10 


340 


40 
20 
27 
7 
4 
2 
5 
4 
4 
3 
2 


118 


170 

123 

123 

26 

21 

6 

47 

33 

8 

26 

12 


595 


Symptoms. — The  disease  is  usually  divided  into  several  stages  : 

1.  The  stage  of  onset.  This  is  usually  attended  by  constitutional 
symptoms,  by  fever  and  headache,  even  by  convulsions  and  delirium ; 
by  vomiting  and  intestinal  disturbance,  or  occasionally  by  severe  pain. 
In  most  instances  the  elevation  of  the  temperature  is  not  extreme,  nor 
is  the  constitutional  disturbance  severe,  and  but  for  the  paralysis,  the 
attack  would  be  considered  as  one  of  the  ordinary  illnesses  so  common 
in  childhood.  In  some  cases  however  the  fever  is  high  and  there  may 
be  convulsions  and  prolonged  unconsciousness,  while  in  others  there 
may  be  no  premonitory  symptoms  whatever,  the  child  is  apparently 
well  at  night,  but  wakens  in  the  morning  paralyzed. 

In  many  instances  the  weakness  caused  by  anterior  poliomyelitis  is 
not  discovered  until  the  child  begins  to  walk,  when  the  awkward  gait, 
or  limp,  or  the  distortion  of  a  foot,  may  make  it  evident. 

In  a  few  hours,  or  a  few  days,  after  the  first  symptoms  of  the  dis- 
ease the  paralysis  appears  ;  its  area  may  extend  slowly  after  it  is  recog- 
nized or  its  extreme  limit  may  be  reached  at  once.  This  original 
paralysis  is  always  greater  than  that  which  finally  persists.  The  dura- 
tion of  the  first  stage  may  be  from  a  few  hours  to  a  week. 

2.  Then  follows  a  stationary  period,  lasting  from  a  week  to  a 
month  ;  the  constitutional  symptoms  cease,  but  the  paralysis  remains. 

3.  This  is  succeeded  by  the  stage  of  partial  recovery,  lasting  from 
one  to  six  months  or  longer.  The  muscles  which  were  paralyzed  be- 
cause of  the  secondary  congestion  and  exudation  about  the  local  mye- 
litis, recover  their  power  in  whole  or  in  part,  while  those  muscles  sup- 
plied from  the  area  in  the  cord  in  which  the  nerve  cells  have  been 
destroyed,  waste  away.  At  this  time  the  contractions  and  distortions 
in  the  paralyzed  part  appear. 

4.  The  chronic  stage.     This  mav  be  considered  to  last  until  adult 


DIAGNOSrS.  443 

age,  or  until  the  ultimate  damage  to  the  individual,  due  to  the  retarda- 
tion df  the  growth  and  unbalancing  of  the  mechanical  equilibrium  of 
the  body,  may  be  summed  up. 

The  sensation  of  the  paralyzed  part  is  not  affected  except  in  the  ex- 
treme cases.  The  temperature  is  lower  from  the  first.  In  many  in- 
stances the  limb  is  not  only  cold,  but  it  is  congested  and  blue.  These 
circulatory  disturbances  are  caused  primarily  by  the  interference  with 
the  vaso-motor  system,  but  they  are  confirmed  later  by  the  atrophy  of 
the  muscles  and  by  the  permanent  contraction  of  the  blood  vessels. 
Thus,  in  general,  the  impairment  of  the  circulation  corresponds  to  the 
degree  of  the  paralysis,  but  not  absolutely  so.  In  certain  cases  the 
paralysis  may  be  very  limited  in  extent,  and  yet  the  limb  may  be  cold 
and  congested,  while  in  others  in  which  the  loss  of  power  is  much 
greater  the  temperature  is  but  slightly  lowered  and  the  color  remains 
normal.  The  same  is  true  of  retardation  of  growth.  In  most  in- 
stances the  ultimate  shortening  of  the  limb  corresponds  to  the  degree 
of  the  paralysis,  and  consequent  loss  of  function  ;  but  occasionally  cases 
are  seen  in  which  the  growth  is  markedly  retarded  although  but  few  of 
the  muscles  are  paralyzed. 

Diagnosis. — It  is  doubtful  if  the  diagnosis  of  acute  anterior  polio- 
myelitis could  be  made  before  the  stage  of  paralysis.  But  after  the 
paralysis  has  appeared  there  should  be  little  difficulty  in  interpreting 
the  symptoms.  It  is  a  disease  usually  of  acute  onset,  followed  by 
paralysis  of  certain  muscular  groups  or  of  entire  members.  It  is  a 
ilaccid  paralysis,  the  reflexes  are  lost,  the  muscles  no  longer  contract 
under  faradism  and  the  reaction  of  degeneration  is  present ;  the  tissues 
waste  and  the  circulation  is  impaired  in  the  affected  parts. 

It  is  usual  to  consider,  first,  in  differential  diagnosis  the  paralyses 
of  cerebral  origin,  but  this  is  more  for  the  purpose  of  calling  attention 
to  the  essential  differences  between  the  two,  than  because  they  are 
likely  to  be  confounded  by  one  acquainted  with  the  ordinary  charac- 
teristics of  cerebral  and  spinal  disease. 

Paralysis  of  Cerebral  Origin  in  Childhood. — In  paralysis  of  cerebral 
origin,  the  common  form  is  hemiplegia.  It  usually  follows  convul- 
sions and  the  intelligence  maybe  impaired.  The  paralysis  is  not  com- 
plete, nor  is  it  limited  to  groups  of  muscles ;  it  is  rather  powerlessness 
or  impairment  of  function,  due  to  loss  of  cerebral  control.  The  reflexes 
are  increased  and  limbs  are  stiffened,  not  flaccid.  The  electrical  reac- 
tions are  not  lost  or  changed  in  quality.  Paralysis  of  cerebral  origin 
may  be  also  paraplegic  or  diplegic  in  its  distribution,  but  in  these  cases 
the  general  characteristics  are  the  same  as  in  the  hemiplegic  form,  ex- 
cept that  the  intelligence  is  more  markedly  affected. 

Other  Forms  of  Spinal  Paralysis. — Transverse  myelitis  is  very  un- 
common in  childhood.  In  this  disease  the  distribution  is  equal,  the  re- 
flexes are  at  first  increased  and  sensation  as  well  as  motion  is  lost. 

Pott's  Paraplegia. — In  this  form  of  paralysis,  also,  the  distribution  is 
equal,  the  reflexes  are  increased  and  the  signs  of  the  disease  of  the  spine 
are  always  present. 


444  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Rheumatism  and  Joint  Disease. — In  orthopsedic  practice,  anterior 
poliomyelitis  is  not  often  seen  in  the  early  stage,  unless  pain  is  a 
prominent  symptom,  when  the  disease  may  be  mistaken  for  rheuma- 
tism or  for  some  form  of  joint  disease.  Cases  of  this  type  are  not  un- 
common. The  muscles  are  sensitive  to  pressure  and  the  movements 
of  the  joints  cause  discomfort.  In  certain  instances  the  paralysis  may 
not  be  apparent  on  the  first  examination  ;  when  it  does  appear  the  di- 
agnosis is,  of  course,  established,  therefore  the  characteristics  of  disease 
of  the  joints  need  not  be  detailed. 

Multiple  Neuritis. — Multiple  neuritis  is  usually  a  sequel  of  infectious 
disease,  or  of  metallic  poisoning.  In  the  cases  due  to  metallic  poison- 
ing with  lead  or  arsenic,  the  paralysis  usually  begins  in  the  extensors 
of  the  hands  and  feet,  and  is  symmetrical  in  its  distribution.  This  is 
true  also  of  the  limited  forms  of  paralysis  following  contagious  diseases 
in  which  the  dorsal  flexors  of  the  feet  are  most  often  involved.  In 
multiple  neuritis  there  is  usually  local  sensitiveness  lasting  a  longer 
time  than  in  poliomyelitis,  and  the  paralysis  is  gradual  in  its  onset  and 
the  sensation,  as  well  as  motion,  is  aifected. 

Diphtheritic  Paralysis. — Diphtheria  is  the  most  common  cause  of 
general  weakness  terminating  in  paralysis,  but  in  these  cases  there  is 
usually  a  history  of  the  preceding  disease.  The  paralysis  appears  first 
in  the  muscles  of  the  throat  and  neck,  and  a  general  and  increasing 
weakness  precedes  for  a  considerable  interval  the  complete  loss  of 
power. 

Weakness.  Pseudo-Paralysis. — Weakness  caused  by  rhachitis,  or 
so-called  pseudo-paralysis,  due  to  this  or  to  other  affections,  is  readily 
distinguished  from  actual  paralysis  by  pricking  the  part  with  a  pin 
when  the  muscular  contraction  will  be  evident.  This  test  of  function 
is  of  value  in  showing  the  distribution  of  the  paralysis.  Loss  of  power 
in  the  tibialis  anticus  muscle,  for  example,  causes  valgus  resembling 
closely  the  ordinary  valgus  due  to  simple  weakness.  In  simple  weak- 
ness the  child  withdraws  the  foot  from  the  point  of  the  pin,  and  the 
ability  to  move  it  in  all  directions  is  very  evident ;  but  if  the  tibialis 
anticus  muscle  is  paralyzed,  the  foot  is  always  flexed  in  the  abducted 
attitude.  The  same  test  may  be  made  for  paralysis  of  other  muscles 
or  muscular  groups.  It  is  a  test  that  is  easily  applied  and  that  is 
especially  useful  in  the  examination  of  young  children. 

Obstetrical  Paralysis. — Paralysis  of  the  arm  is  infrequent  as  com- 
pared with  that  of  the  lower  extremities.  This  form  might  be  mis- 
taken for  obstetrical  paralysis,  but  the  history  of  the  disability  and  its 
distribution  should  make  the  diagnosis  clear. 

Prognosis. — Only  in  very  rare  instances  does  the  disease  of  itself 
cause  death.  The  prognosis  as  to  function  depends  upon  the  area  of 
the  destructive  disease  of  the  cord,  and  upon  the  treatment  of  the 
weakened  or  disabled  part. 

As  has  been  stated  the  extent  of  the  primary  paralysis  is  very  much 
greater  than  that  which  ultimately  remains  when  the  inflammatory 
chans-es  about  the  diseased  area  in  the  cord  have  subsided. 


CAUSES  OF  DEFORMITY.  445 

The  Electrical  Test. — During  the  early  stages  of  the  disease  the 
degrefe  of  final  paralysis  may  be  fairly  estimated  by  the  electrical  reac- 
tion. Within  a  week  after  the  initial  paralysis  the  reaction  to  the  far- 
adic  current  in  the  muscles  and  nerves  is  lessened  and  finally  is  lost. 
If  the  faradic  irritability  is  retained  in  the  paralyzed  muscles,  or  if  it 
is  merely  diminished,  recovery  may  be  predicted.  The  muscles  which 
no  longer  react  to  the  faradic  irritation  may  still  be  made  to  contract 
by  the  galvanic  current.  In  normal  muscles  the  reaction  is  greatest 
at  the  closing  of  the  negative  pole.  In  the  paralyzed  muscles  the  re- 
action is  slower,  it  requires  greater  stimulation  and  the  contraction  is 
greater  at  the  closing  of  the  positive  pole.  This  is  known  as  the  reac- 
tion ol  degeneration.     The  loss  of  faradic  reaction  and  the  change  in 

Fig.  309. 


Anterior  poliomyelitis.    Extreme  flexion  deformity  at  the  hips  induciug  the  quadrupedal  attitude. 

(GiBNEY.) 

the  galvanic  reaction  indicate  that  the  function  of  the  affected  muscle 
is  lost,  although  certain  of  its  fibers  may  in  time  regain  their  power. 

The  Effects  of  Paralysis  of  Dififerent  Muscles  and  G-roups  of  Muscles 
upon  Function. — The  interest  in  anterior  poliomyelitis  lies  in  its  imme- 
diate and  ultimate  effect  upon  the  functional  ability  of  the  individual. 
These  effects  may  be  classified  as  Deformity  of  the  part  directly  involved. 
The  general  effects  of  weakness,  deformity  and  loss  of  growth  upon  the 
body  as  a  whole. 

Causes  of  Deformity. — The  deformities  of  anterior  poliomyelitis 
are  caused  : 

1 .  By  the  force  of  gravity. 

2.  By  the  unopposed  action  of  the  muscles  whose  power  remains. 


446  DISEASES  OF  THE  NERVOUS  SYSTEM. 

3.  By  functional  use. 

All  these  and  other  less  important  causes  of  deformity  are  of  course 
combined  in  most  instances.  The  relative  importance  of  each  factor 
varies,  according  to  the  muscular  group  that  is  involved,  with  the  age 
of  the  patient  and  with  the  work  to  which  the  part  is  subjected.  The 
influence  of  the  different  factors  can  be  studied  best  in  the  foot. 

Muscular  Action  and  Gravity. — In  by  far  the  larger  number 
of  cases,  one  or  more  of  the  anterior  muscles  of  the  leg,  dorsal  flexors 
of  the  foot,  are  involved.  This  is  illustrated  by  the  statistics  of  ac- 
quired talipes,  tabulated  elsewhere,  in  which  the  equinus  predominates 
over  the  varieties  of  calcaneus  deformity  in  a  proportion  of  three  to  one. 

If  the  anterior  muscles  are  paralyzed  in  a  child  before  the  walking 
age,  the  foot  drops  under  the  influence  of  the  force  of  gravity  into  the 
attitude  of  equinus.  If  this  attitude  is  allowed  to  persist,  the  muscles 
on  the  posterior  aspect  of  the  limb  accommodating  themselves  to  the 
habitual  attitude,  in  time  become  structurally  shortened.  In  such 
cases  the  equinus  deformity  is  caused  by  the  force  of  gravity ;  it  is  in- 
creased by  muscular  action  and  it  is  fixed  by  muscular  adaptation. 
That  deformity  is  not  caused  directly  by  muscular  action  is  shown  by 
the  fact  that  it  may  be  prevented  by  stimulating  the  paralyzed  muscles 
from  time  to  time  with  galvinism,  or  even  by  passive  motion  to  the 
limit  of  dorsal  flexion.  Deformity  is  thus  prevented,  not  by  opposing 
muscular  action,  but  by  preventing  muscular  adaptation  and  structural 
change,  by  stretching  the  active  muscles  to  their  full  limits  from  time 
to  time.  In  the  instance  cited,  gravity  and  muscular  activity  are  com- 
bined in  the  production  of  equinus,  but  in  other  instances,  gravity  and 
muscular  power  may  be  opposed  to  one  another.  If,  for  example,  the 
calf  muscle  is  paralyzed  while  the  anterior  group  retains  its  power,  the 
deformity  of  calcaneus  does  not  appear  until  the  child  begins  to  use 
the  foot,  when  the  peculiar  helplessness  calls  attention  to  the  disability, 
if  the  diagnosis  has  not  been  made  before.  Thus  it  is  that  equinus 
may  be  present  when  the  child  is  still  in  arms,  while  the  opposite  de- 
formity develops  much  more  slowly. 

Habitual  Posture. — There  are  other  cases  in  which  every  vestige 
of  muscular  power  is  lost,  in  which  the  foot  dangles.  In  this  class 
there  is  no  adaptive  shortening  of  the  muscles  to  fix  the  foot  in 
the  habitual  attitude,  consequently  deformity  is  slow  in  making  its  ap- 
pearance ;  it  is  not  often  extreme,  and  it  becomes  fixed  only  by  the 
structural  shortening  of  the  inactive  tissues,  the  ligaments  and  fasciae. 
There  are,  of  course,  other  causes  for  habitual  posture  than  the  force 
of  gravity  and  muscular  action,  such  as,  for  example,  the  position  of 
convenience  in  which  a  weak  or  disabled  part  might  be  placed,  but 
such  causes  of  deformity  may  be  considered  as  instances  of  functional 
use  or  rather  of  adaptation  to  local  weakness. 

Functional  Use  as  a  Cause  of  Deformity. — Thus  far  the  force 
of  gravity,  unbalanced  muscular  power  and  the  structural  changes  in  the 
tissues  have  been  considered  in  the  etiology  of  deformity,  as  it  might 
develop  in  infancy.     When,  however,  the  patient  stands  and  walks^ 


THE  DEFORMITIES  OF  AI^TERIOR  P0LI03IYELITIS. 


447 


Fig.  310. 


existing  deformities  are  exaggerated  and  distortions  are  developed  and 
confirmed  by  the  weight  of  the  body  falling  on  the  unbalanced  part, 
and  by  the  action  of  the  muscles  in  the  attempt  to  supply  the  function 
of  those  that  are  paralyzed.  Thus  it  is  that  deformity  develops  far 
more  rapidly  when  a  fair  amount  of  muscular  power  remains,  than 
when  it  is  completely  lost.     (See  talipes.) 

Subluxation. — Aside  from  the  distortions  due  to  the  causes  that 
have  been  mentioned,  there  are  others  caused  simply  by  weakness  ;  for 
example,  when  laxity  of  ligaments 
and  the  failure  of  muscular  sup- 
port permits  distortion  of  a  limb 
and  subluxation  or  even  displace- 
ment at  a  joint.  (Figs.  311,  312.) 
Actual  displacement  is  uncommon 
and  occurs  practically  only  at  the 
hip.  In  such  cases  there  is  usually 
flexion  deformity  of  the  limb.  The 
femur  is  suspended  by  the  contract- 
ed tissues  attached  to  the  anterior 
superior  spine.  This  unyielding 
band  forms  a  fulcrum  by  means  of 
which  force  applied  at  the  knee 
may  cause  sudden  displacement  of 
the  head  of  the  femur  inward  or 
upward  and  backward .JJJJ^^§pt?^ 

Deformities  of  the  Upper  Extrem- 
ity.— Deformities  caused  by  paraly- 
sis of  the  muscles  of  the  shoulder 
and  upper  arm  are  usually  slight 
because  the  part  is  not  subjected 
to  the  strain  of  weight -bearing, 
and  because  the  force  of  gravity  is 
opposed  to  muscular  contraction. 
In  these  cases  the  loss  of  support 
and  the  tension  on  the  capsule  al- 
lows a  considerable  separation  of 
the  joint  surfaces  so  that  the  atro- 
phied head  of  the  humerus  may  be 
displaced  forward  or  backward ; 
but  there  is  not  often  fixed  dis- 
placement, and  consequently  distor- 
tion due  to  this  cause  is  very  un- 
usual. 

Paralysis  of  the  muscles  of  the 
forearm  and  of  the  hand  is  followed  after  a  time  by  deformity  of  the 
fingers  caused  primarily  by  unopposed  muscular  action,  secondarily  by 
accommodation  and  atrophy. 

Deformities  of  the  Neck. — Paralysis  of  one  or  more  of  the  muscles 


Anterior  poliomyelitis.  Duration  seven 
years.  Showing  atrophy,  and  slight  lateral  cur- 
vature of  the  spine.  2J^  inches  of  shortening. 


448 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


of  the  neck  may  induce  a  paralytic  torticollis.     This  is,  however,  ex- 
tremely rare. 

Deformities  of  the  Trunk. — Paralysis  of  the  muscles  of  the  trunk 
may  induce  distortion  and  extreme  lateral  curvature  of  the  spine.  This 
curvature  is  not  usually  caused,  as  might  at  first  appear,  by  contrac- 
tion of  the  active  muscles  and  thus  a  bending  of  the  trunk  with  a  con- 

FiG.  311. 


Anterior  poliomyelitis  causing  genu  recurvatum.     (See  Fig.  312.) 


vexity  toward  the  weaker  side.  As  a  rule,  the  curvature  is,  as  a  whole, 
in  the  opposite  direction.  This  is  explained  by  the  fact  that  if  the 
paralysis  is  extensive  enough  to  cause  distortion  of  the  trunk,  and  if  it 
is  limited  to  one  side,  the  muscles  of  respiration  on  that  side  are  also 
paralyzed  or  weakened  so  that  the  chest  wall  becomes  inactive  and 
collapses  while  the  opposite  side  increases  in  volume  and  lung  capacity 
in  taking  on  the  extra  work  ;  thus  it  expands,  drawing  the  weaker  and 


RETARDATION  OF  GROWTH.  449 

atrophied  side  into  a  concavity.  The  same  effect  is  observed  when 
the  a?m  and  the  shoulder  muscles  are  paralyzed,  the  spine  bend- 
ing toward  the  side  that  is  still  active. 

Paralysis  of  the  posterior  group  of  muscles,  if  extreme,  might  cause 
a  kyphosis.  Paralysis  of  the  muscles  of  the  abdomen  may  induce 
lordosis,  but  in  this  group  ot  cases  the  lower  extremities  are  usually 
involved  and  the  secondary  distortions  due  to  posture  and  to  func- 
tional use  mask  the  direct  effect  of  the  paralysis  of  the  muscles  of  the 
trunk.  And  again  the  over-use  of  the  shoulder  muscles  in  patients 
whose  lower  extremities  are  paralyzed,  and  the  suspension  of  the 
body  on  crutches  in  walking  modify  the  ultimate  effects  in  these  cases 
in  which  the  paralysis  is  wide-spread  in  its  area.    (See  lateral  curvature.) 

Retardation  of  Growth  and  Secondary  Deformities. — The  effects  of 
anterior  poliomyelitis  are  not  limited  to  the  paralysis  and  to  atrophy 
of  the  muscles,  but  all  the  component  tissues  of  the  affected  limb  are 
involved  as  well.     The  bones  become  relatively  atrophied  and  their 

Fig.  312. 


Anterior  poliom3'elitis.    Paralysis  of  muscles  at  the  hip  allows  subluxatiou  of  the  femur. 
The  same  patient  as  in  Fig.  311. 

growth  is  retarded  to  a  degree  proportionate  to  the  extent  of  the  par- 
alysis and  to  the  functional  disability  that  has  resulted.  It  has  been 
stated  however  that  retardation  of  growth  does  not  always  correspond 
to  the  amount  of  paralysis.  In  some  instances  paralysis  of  a  single 
muscle  which  does  not  seriously  compromise  the  function  of  the  part 
is  attended  with  greater  shortening  of  the  limb  than  in  other  cases  in 
which  the  paralysis  is  far  more  extensive.  Thus  it  may  be  inferred 
that  certain  cells  in  the  spinal  cord  are  especially  concerned  in  the 
growth  and  nutrition  of  the  bones  and  that  interference  with  the  function 
of  these  cells  may  not  correspond  absolutely  to  the  extent  of  the  de- 
structive process.  However  this  may  be,  it  is  certain  that  atrophy 
and  retardation  of  growth  are  much  greater  when  a  limb  is  not  used 
than  when  by  the  aid  of  apparatus  it  has  been  enabled  to  carry  out,  in 
part  at  least,  its  proper  function.  It  is  evident  also  that  retardation 
of  growth  will  be  more  marked  during  the  period  of  rapid  develop- 
ment ;  thus  the  younger  the  patient  the  greater  should  be  the  ultimate 
inequality  of  the  limbs. 
29 


450  DISEASES  OF  THE  NEBVOUS  SYSTEM. 

Retard ATiox  of  Growth. — The  ultimate  shortening  varies  from 
one  to  three  inches.  In  the  slighter  degrees  of  paralysis  affecting  the 
leg,  the  shortening  may  be  less  than  an  inch,  but  when  the  thigh  muscles 
are  paralyzed  also,  it  maybe  much  more.  (Fig.  310.)  This  inequality 
is  usually  very  evident  in  the  size  of  the  two  feet. 

When  both  limbs  are  paralyzed  so  that  locomotion  is  very  seriously 
interfered  with,  the  retardation  of  growth  is  especially  marked  and  the 
contrast  between  the  trunk  of  the  patient  and  the  attenuated  lower  ex- 
tremities is  very  striking. 

Secoxdaey  deformities  must  include  besides  those  already  men- 
tioned the  compensatory  distortions  of  the  trunk  that  may  follow 
paralysis  of  the  limbs.  Thus  a  short  leg  might  cause  a  lateral  curva- 
ture of  the  spine  or  great  flexion  contraction  of  the  thigh  might  induce 
abnormal  lordosis.  As  a  matter  of  fact,  the  final  effects  of  disabilities 
of  this  character  are  very  complex  and  are  influenced  by  many  factors 
of  which  only  a  general  indication  is  practicable. 

Treatment. — The  treatment  of  the  acute  stage  of  anterior  polio- 
myelitis is  symptomatic.  If  the  diagnosis  has  been  made,  such  measures 
as  would  tend  to  relieve  the  congestion  about  the  diseased  area  should 
be  employed ;  cathartics,  sedatives,  and  counter-irritation  of  the  spine, 
for  example.  When  the  acute  symptoms  have  subsided,  local  treat- 
ment to  maintain  as  far  as  is  possible  the  nutrition  of  the  muscles,  to  pre- 
vent deformity  and  to  relieve  the  strain  upon  the  weakened  tissues  is 
indicated.  The  nutrition  of  the  parts  may  be  improved  by  massage, 
by  muscle  beating,  by  the  direct  application  of  heat  to  the  cold  ex- 
tremities, and  by  the  use  of  galvanism,  as  long  as  it  will  produce  con- 
tractions in  the  paralyzed  muscles. 

Deformity  may  be  prevented  by  moving  each  joint  to  the  limit  of 
the  range  of  motion  in  all  directions  several  times  a  day  and  by  sup- 
porting the  limb  with  appropriate  apparatus.  Deformity  in  those  parts 
in  which  it  is  favored  by  muscular  action  and  by  the  force  of  gravity,  ap- 
pears much  more  rapidly  than  is  generally  supposed.  The  indications 
of  equinus,  for  example,  are  apparent  in  a  very  few  weeks  after  paraly- 
"sis  of  the  anterior  muscles  of  the  leg.  The  first  indication  of  such  de- 
formity in  this  class  is  the  discomfort  caused  by  passively  moving  the 
foot  toward  dorsal  flexion.  This  limitation  of  the  range  of  motion 
rapidly  increases,  and  as  it  increases  it  is  confirmed  by  muscular  adap- 
tation and  finally  by  structural  shortening. 

The  Principles  of  Mechanical  Treatment. — The  object  of  a  brace  is  to 
prevent  the  deformity  due  to  weakness,  to  utilize  the  muscular  power 
that  remains  and  thus  to  enable  the  disabled  member  to  carry  out  its 
function.  As  each  muscle  has  an  essential  function,  the  paralysis  of 
any  muscle  must  be  followed  by  a  certain  disability  and  usually  by  de- 
formity. Muscles  vary  in  importance  as  they  do  in  strength  and  the 
ultimate  disability  caused  by  paralysis  may  be  predicted  very  accurately 
by  one  who  is  familiar  with  this  function. 

Paralysis  of  the  Anterior  Muscees  of  the  Leg. — Paral- 
ysis of  the  anterior  leg  group  causes  the  so-called  steppage  gait,  the  toes 


MECHANICAL  TREATMENT. 


451 


C^ 


<^r33 


drag  on  the  floor  when  the  limb  is  swung  forward  and  this  necessitates 
an  awkward  lifting  of  the  knee.  The  result  of  such  paralysis  is  equi- 
nus.     Slight  equinus  has 

a  tendency  to  throw  the  Fig.  313.  Fig.  314. 

knee  backward,  "recur- 
vatum,"  in  order  that 
the  patient  may  place  the 
entire  sole  on  the  ground. 
More  marked  equinus 
obliges  the  patient  to  bear 
the  weight  entirely  on 
the  front  of  the  foot  and 
causes  flexion  both  at 
the  knee  and  hip.  If 
but  one  of  the  muscles 
of  the  anterior  group  is 
paralyzed  the  tendency 
to  equinus  is  in  so  far 
lessened,  but  there  is 
an  inclination  to  lateral 
distortion.  Paralysis  of 
the  anterior  muscles 
causes  an  awkward  gait 
and  often  deformity, 
but  the  propelling  force 
of  the  limb  remains. 
The  indication  for  support  is  simple,  to  prevent  the  foot  from  drop- 
ping to  the  extent  that  incommodes  the  patient,  or  practically  to  hold 
the  foot  at  a  right  angle  with  the  leg. 

Paralysis  of  the  Posterior  Muscles  of  the  Leg. — If,  on 
the  other  hand,  the  calf  muscles  are  paralyzed  the  resistance  of  the  foot 
is  lost  and  it  is  simply  dorsi-flexed  when  weight  is  thrown  upon  it. 
Thus  the  brace  must  be  arranged  to  prevent  dorsal  flexion,  and  strong 
enough  to  support  the  strain  which  is  transmitted  from  the  foot  plate 
of  the  brace  to  the  front  of  the  leg.  The  various  weaknesses  and  de- 
formities of  the  foot  and  the  means  of  treating  them  are  described  at 
length  elsewhere.     (See  talipes.) 

Paralysis  of  the  calf  muscles  not  only  affects  the  foot,  but  it  weakens 
the  knee  as  well,  and  genu  recurvatum  is  often  a  secondary  effect.  In 
many  instances  therefore  it  will  be  necessary  to  support  the  knee  as 
well  as  the  ankle  during  the  earlier  stages  of  the  treatment. 

Paralysis  of  the  Thigh  Muscles. — Paralysis  of  the  quadri- 
ceps extensor  muscle  causes  primarily  a  peculiar  gait.  The  patient, 
unable  to  extend  the  leg  upon  the  thigh,  throws  or  swings  it  forward, 
then  locks  the  joint  by  direct  contact  of  the  bones  and  by  the  resist- 
ance of  the  posterior  tissues,  by  inclining  the  body  somewhat  forward 
as  the  weight  falls  upon  it.  In  this  manner  again  the  knee  may  be 
over-extended.     Or  if  extension  is  checked  by  shortening  of  the  tissues, 


The  Judson  brace  for  paralysis  of  the  quadriceps  extensor  mus- 
cle in  connection  with  deformity  of  the  foot. 


452 


DISEASES   OF  THE  NERVOUS  SYSTEM. 


induced  possibly  by  habitual  assumption  of  the  sitting  posture,  the  pa- 
tient being  unable  to  lock  the  joint  effectively  by  complete  contact  of 
the  bones,  often  trips  and  falls  because  of  the  insecurity  of  the  sup- 
port. When  in  the  normal  subject  the  weight  is  borne  upon  one 
leg  in  the  attitude  of  rest,  in  which  the  muscles  are  thrown  out  of 


Fig.  316. 


Fig.  315 


A  brace  for  complete  paralysis  ol'  the 
limb,  sbo win  g  a  form  of  lock  at  the  knee  and 
a  limited  joint  at  the  ankle. 


Anterior  poliomyelitis.     Paralysis  of  the  ante- 
rior and  posterior  muscles.    Right  leg. 


action,  the  knee  joint  is  locked,  but  the  insecurity  of  this  support  is 
illustrated  by  the  school  boy's  trick  of  striking  the  back  of  the  knee 
with  the  hand  when,  the  muscles  being  taken  unawares,  the  person  falls 
to  the  ground.  This  insecurity  is  constant  when  the  extensor  of  the 
leg  is  paralyzed. 

Paralysis  limited  to   the  quadriceps  extensor  muscle  is,  however,. 


MECHANICAL  TREATMENT, 


453 


very  unusual.  In  almost  all  cases  some  of  the  leg  muscles  are  involved 
also,  and  the  brace  usually  must  serv^e  to  support  the  foot  as  well  as 
the  knee.  In  its  ordinary  form  such  a  brace  is  constructed  of  two 
lateral  upright  bars,  reaching  nearly  to  the  pubes  on  the  inner  and  to 
the  trochanter  on  the  outer  side,  joined  to  one  another  by  bands  pass- 
ing beneath  the  thigh  and  the  calf,  and  attached  to  a  light  steel  foot 
jjlate.  If  the  dorsal  flexors  of  the  foot  are  paralyzed  the  ankle  joint 
is  arranged  to  allow  dorsal  flexion,  but  to  prevent  extension  beyond 
the  right  angle.  If  the  calf  muscle  is  paralyzed  a  reverse  catch  is  used, 
or  the  uprights  are  attached  directly  to  the  foot  plate  without  a  joint 

Fig.  317. 


Brace  for  complete  paralysis  of  the  anterior  muscles  of  the  limb  ;  before  and  after  covering. 

(Fig.  314)  ;  or  the  so-called  limited  joint  allowing  only  a  few  degrees 
of  motion  in  either  direction  is  used.  (Fig.  315.)  (See  talipes.)  In 
the  treatment  of  young  children  the  joint  is  also  omitted  at  the  knee, 
the  limb  being  firmly  held  in  the  extended  position  during  the  active 
period.  (Figs.  314  and  3 17.)  This  is  of  advantage  because  the  joint 
is  the  weakest  part  of  the  brace  and  soon  becomes  loose  under  the  se- 
vere strain  to  which  it  is  subjected.  In  older  subjects  a  joint  is  ar- 
ranged with  a  spring  catch,  the  brace  being  held  in  the  straight  posi- 
tion when  the  patient  is  walking  about,  but  allowing  flexion  when  the 
sitting  posture  is  assumed.     This  is  of  course  a  great  convenience. 


454  DISEASES  OF  THE  NERVOUS  SYSTEM. 

(Fig.  315.)  In  fitting  the  brace  the  lateral  bars  should  be  adjusted 
to  support  the  limb  without  uncomfortable  pressure,  and  the  joints 
should  be  exactly  opposite  the  normal  centers  of  motion.  The  thigh 
and  leg  bands  should  be  properly  fitted  to  the  contour  of  the  soft 
parts  so  that  half  the  limb  is  contained  within  them.  These  are 
smoothly  covered  with  leather  and  the  limb  is  held  in  position  by  leather 
bands  that  complete  the  circumference.  Other  bands  are  applied  across 
the  front  or  back  of  the  limb,  either  to  support  it  or  to  fix  it  firmly  in 
place.  In  the  ordinary  brace  without  the  joint  at  the  knee,  there  are 
three  anterior  bands,  one  across  the  front  of  the  thigh,  another  across 
the  leg,  and  the  third,  a  wide  knee  cap,  supports  the  greater  part  of 
the  strain.     (Fig.  317.) 

Paralysis  of  the  Muscles  of  the  Hip. — The  effect  of  paralysis 
of  the  muscles  about  the  hip  is  difficult  to  describe,  as  in  these  cases  many 
other  muscles  are  usually  involved.  If  all  the  muscles  are  paralyzed 
the  thigh  dangles.  This  is  however  very  unusual,  for  the  tensor  va- 
ginae femoris  almost  always  retains  its  power  and  is  one  of  the  causes 
of  flexion  deformity  which  is  so  often  present  in  cases  of  this  character. 

Paralysis  of  the  ilio-psoas  muscle  makes  it  impossible  for  the  pa- 
tient to  flex  the  thigh  directly.  If  the  adductors  are  paralyzed  he 
must  lift  the  thigh  with  the  hand  when  adduction  is  desired.  Paralysis 
of  the  glutei  is  made  evident  by  the  atrophy  and  by  the  weakness  of 
the  extending  power  of  the  limb. 

The  distribution  of  the  paralysis  of  the  muscles  of  the  hip  may  be 
ascertained  by  placing  the  patient  in  the  recumbent  posture ;  the  leg 
is  then  lifted  from  the  table,  and  by  placing  the  thigh  in  different  po- 
sitions the  ability  of  the  patient  to  move  it  may  be  tested,  in  older 
subjects  by  voluntary  effort,  in  the  younger  ones  by  pricking  the  part 
slightly  with  a  pin. 

General  weakness  of  the  muscles  of  the  hip  causes  an  awkward, 
insecure  gait  accompanied  usually  by  outward  rotation  of  the  limb, 
and  as  has  been  stated  there  is  almost  always  accompanying  paralysis 
of  other  muscles  of  the  extremity.  In  such  cases  a  pelvic  band  must 
be  attached  to  the  leg  brace.  The  pelvic  band  is  made  of  sheet  steel  of 
about  18  gauge,  two  inches  wide,  fitted  to  the  pelvis  which  it  encircles 
midway  between  the  crest  of  the  ilium  and  the  trochanter.  At  this 
point  it  is  attached  to  the  brace  by  a  free  joint.  (Fig.  317.)  When 
the  band  is  accurately  adjusted  and  strapped  firmly  about  the  pelvis, 
the  necessary  security  is  assured  and  the  attitude  of  the  limb  in  walking 
can  be  regulated.  If  greater  support  is  desired  a  perineal  band  may 
be  applied  as  described  in  the  chapter  on  disease  of  the  hip  joint. 

If  both  limbs  are  paralyzed  double  braces  must  be  used.  If  the 
muscles  of  the  lower  part  of  the  back  are  much  weakened  the  pelvic 
band  may  be  replaced  by  a  corset  or  some  form  of  back  brace.  For- 
tunately these  cases  are  uncommon. 

Paralytic  Scoliosis. — Paralytic  scoliosis  requires  the  support  of 
corsets  or  braces  as  a  rule,  such  as  are  used  in  the  treatment  of  other 
forms  of  distortion  of  the  back.     (See  lateral  curvature.) 


OPERATIVE  TREATMENT.  455 

Pabalysis  op  the  Aem. — Paralysis  of  the  arm  is  uncommon  and 
treatment  is  rarely  demanded. 

In  some  instances  a  shoulder  support  may  be  of  service  or  a  brace 
to  hold  the  arm  at  a  right  angle  if  the  biceps  is  paralyzed.  If  the 
muscles  of  the  scapula  retain  their  power  the  operation  of  arthrodesis 
might  be  of  service  in  fixing  the  dangling  joint,  and  the  same  opera- 
tion might  be  useful  at  the  elbow.  It  is  of  course  evident  that  one 
of  the  lower  extremities,  although  hopelessly  weakened,  may  be  braced 
so  that  it  may  serve  as  a  simple  prop  to  bear  weight,  but  as  the  func- 
tion of  the  arm  is  quite  different,  extensive  paralysis  of  its  muscles 
makes  it  practically  useless  to  the  individual. 

Operative  Treatment.  The  Reduction  of  Deformity. — In  a  large 
proportion  of  the  cases  of  anterior  poliomyelitis  the  patients  are  not 
seen  by  the  orthopaedic  surgeon  until  months  or  years  have  elapsed 
since  the  original  attack.  They  are  then  brought  for  treatment  be- 
cause of  secondary  deformity  often  of  an  extreme  degree.  At  least  half 
of  the  cases  of  talipes  are  due  to  this  cause  and  with  the  deformity  of 
the  foot  are  often  combined  other  distortions  varying  in  degree  with 
the  extent  of  the  paralysis.  Many  of  the  patients  hobble  about  on  a 
distorted  foot,  others  use  crutches  and  in  a  smaller  number  the  only 
method  of  locomotion  is  creeping  on  all  fours.  In  the  cases  in  which 
the  patient  has  habitually  used  crutches  allowing  the  paralyzed  limb  to 
"  dangle  "  there  is  usually  marked  flexion  at  the  three  joints.  The 
thigh  is  flexed  upon  the  pelvis,  the  leg  is  flexed  upon  the  thigh  and 
the  foot  hangs  downward  and  inward  (plantar-flexed)  in  an  attitude  of 
equino-varus.  No  matter  how  extreme  the  paralysis  of  a  lower  ex- 
tremity may  be  the  limb  may  be  made  useful  as  a  prop,  when  properly 
braced  and  this  prop  will  enable  the  patient  to  dispense  with  the  use  of 
crutches  and  thus  free  the  arms  from  unnecessary  work.  Even  if  both 
limbs  are  paralyzed  they  may  at  least  serve  as  supports  to  enable  the 
patient  to  stand  erect  and  to  propel  himself  with  the  aid  of  crutches. 
If  the  limb  has  been  disused  for  a  long  time,  the  atrophy  is  usually 
extreme,  the  bones  are  fragile  and  the  growth  has  been  greatly  retarded 
as  compared  with  those  limbs  in  which  deformity  has  been  prevented 
and  in  which  the  weight  of  the  body  has  been  sustained  in  functional 
use.  In  this  class  of  cases  the  first  step  must  be  the  reduction  of  de- 
formity :  the  foot  must  be  brought  to  a  right  angle  with  the  leg,  the 
limb  must  be  brought  to  the  straight  line,  and  the  flexion  at  the  hip 
must  be  overcome  in  order  to  enable  the  patient  to  stand  erect  without 
bending  the  spine  forward  into  an  extreme  compensatory  lordosis. 

Acquired  deformity  of  the  foot  is  far  less  resistant  than  is  the  con- 
genital form  and  by  tenotomy  and  the  proper  application  of  force  it 
may  be  readily  straightened,  usually  at  one  sitting. 

The  flexion  contraction  at  the  knee  may  be  overcome  also  by  careful 
and  persistent  manual  stretching  combined,  if  necessary,  with  division 
of  the  contracted  tissues  on  the  posterior  aspect  of  the  joint. 

The  flexion  deformity  at  the  hip  is  usually  fixed  by  the  contraction 
of  the  tissues  about  the  anterior  superior  spine  of  the  ilium,  including 


456  DISEASES  OF  THE  NERVOUS  SYSTEM. 

the  tensor  vaginae  femoris  muscle  which  is  rarely  paralyzed.  These 
tissues  together  with  the  fascia  may  be  divided  subcutaneously,  or  by 
open  incision  if  necessary  ;  after  which  the  deformity  may  be  reduced 
by  gradual  forcible  extension  of  the  thigh  while  the  pelvis  is  fixed 
by  flexing  the  other  limb  upon  the  body.  When  the  contraction  de- 
formities are  reduced,  lateral  deviation  at  the  knee  is  corrected,  if  it 
be  present,  in  the  same  manner,  and  the  bony  points  having  been  care- 
fully protected  by  padding  a  long  spica  plaster  bandage  is  applied  to 
fix  the  limb. 

The  lesser  degrees  of  deformity  may  be  reduced  by  other  means,  for 
examplp,  by  repeated  applications  of  plaster  bandages  under  slight  cor- 
rective force,  or  by  manipulation,  or  by  braces  and  bandaging. 

Paralytic  knock  knee  may  be  overcome  by  the  Thomas  knock  knee 
brace,  and  this  brace  when  attached  to  a  pelvic  band  is  a  useful  form 
of  support  in  the  routine  treatment  of  paralysis  of  the  legs.  (See 
knock  knee.) 

The  Thomas  caliper  knee  brace  is  another  cheap  and  useful  support. 
It  is  of  especial  service  when  there  is  flexion  or  lateral  deformity  of 
the  limb.     (Fig.  230.) 

When  distortion  has  been  overcome  and  when  functional  use  has 
been  made  possible  by  proper  support,  the  development  of  active  mus- 
cles which  had  been  thrown  out  of  use  by  the  distortions,  and  of  those 
in  which  part  of  the  muscular  substance  has  been  retained  is  surprising. 
In  many  of  these  cases  the  distortions  which  developed  during  the  tempo- 
rary paralysis  had  alone  prevented  recovery  and  this  latent  power  may 
be  revived  even  after  years  of  disuse.  Thus  in  many  instances  prog- 
nosis is  impossible  until  the  deformities  have  been  corrected  and  until 
the  limb,  properly  supported,  has  been  enabled  to  resume  its  function. 

Tendon  Transplantation. — This  operation  is  best  adapted  to  the  treat- 
ment of  distortions  of  the  foot  caused  by  paralysis  of  the  muscles  of 
the  leg,  and  the  procedure  is  described  at  length  in  that  section. 

In  certain  cases  of  paralysis  of  the  quadriceps  extensor  when  the 
sartorius  muscle  has  remained  active,  if  may  be  utilized  to  better  ad- 
vantage by  attaching  it  to  the  insertion  of  that  muscle,  as  suggested  by 
Goldthwait.  Muscle  or  tendon  transplantation  may  be  of  service,  in 
exceptional  cases,  in  other  situations. 

Paralysis  of  the  muscles  of  the  arm  and  hand  is  unusual.  The 
operation  of  tendon  shortening  combined  with  transplantation  of  the 
tendons  of  one  or  more  active  muscles  may  be  of  service  in  the  treat- 
ment of  wrist  drop,  and  opportunities  may  suggest  themselves  in  other 
situations  whenever  it  is  possible  to  utilize  the  muscular  power  to  bet- 
ter advantage. 

Arthrodesis. — As  has  been  stated  of  tendon  transplantation,  arthro- 
desis is  of  greatest  service  at  the  ankle  joint  where  it  may  serve  to  fix 
the  foot  at  a  right  angle  with  the  leg.  (See  talipes.)  In  exceptional 
cases  arthrodesis  or  excision  at  the  knee  may  be  advisable  in  the 
older  patients,  but  in  young  subjects  the  strain  upon  the  long,  weak 
lever  formed  by  the  two  bones  will  almost  always  induce  deformity. 


RECAPITULATION  OF  TREATMENT. 


457 


Fig.  318. 


Arthrpdesis  at  the  hip  might  be  of  service  in  complete  paralysis  of  the 
pelvic  muscles,  at  the  shoulder  when  the  muscles  attached  to  the  scapula 
are  active,  and  in  exceptional  cases  at  the  elbow  and  wrist  to  assure  an 
improved  position. 

Osteotomy. — In  rare  instan- 
ces, particularly  in  the  extreme 
deformities  in  the  adult,  oste- 
otomy of  the  femur  at  the  hip 
or  knee  may  be  necessary  in 
order  to  overcome  resistant  dis- 
tortion. 

Recapitulation  of  Treat- 
ment.— This  consists  in  support 
and  electrical  stimulation  of  the 
muscles  during  the  period  of  re- 
covery, together  with  a  suitable 
brace  to  hold  the  limb  in  the  best 
possible  position  for  usefulness 
when  the  final  extent  of  the  par- 
alysis has  become  evident.  With 
the  support,  any  treatment  that 
will  improve  the  nutrition  of  the 
part  is  of  service ;  massage  and 
muscle  beating  are  of  especial 
value.  The  limb  in  which  the 
circulation  is  deficient  should  be 
protected  from  the  cold  by  pro- 
per covering,  and  its  nutrition 
may  be  improved  by  the  direct 
application  of  heat,  the  hot-air 
or  hot-water  bath  both  being 
useful.  Above  all  else,  func- 
tional use,  which  is  made  pos- 
sible by  apparatus,  is  of  the  first 
importance  in  preserving  and 
stimulating  whatever  muscular 
power  remains;  and  special  gym- 
nastic exercises  to  this  end  may 
be  employed  if  practicable.    The 

prevention  of  deformity  during  the  growing  period  is  of  great  importance. 
Every  morning  and  night  the  joints  of  the  paralyzed  part  should  be  pas- 
sively moved  to  the  normal  limits  in  all  directions  in  order  to  prevent 
the  gradual  limitation  of  the  range  of  motion  which  is  the  first  indica- 
tion of  deformity.  Lateral  deviation  of  the  limb  may  be  prevented 
by  passive  manipulation  and  by  the  support  that  may  be  exercised  by 
modification  of  the  brace  that  may  be  employed.  Braces  should  be 
strong,  and  as  simple  as  may  be  in  construction.  Elastic  bands  and 
springs,  applied  with  the  design  of  replacing  paralyzed  muscles  are  of 


Leg  brace  with  pelvic  band.  Double  uprights. 
No  joint  at  knee.  Foi-  paralysis  of  the  anterior 
thigh  and  leg  muscles. 


458  DISEASES  OF  THE  NERVOUS  SYSTEM. 

little  practical  use,  since  they  are  ineffective  in  action,  difficult  to  adjust 
and  easily  disarranged.  The  parent,  when  treatment  is  begun,  must 
be  impressed  with  the  fact  that  a  brace  must  be  strong  enough  to 
serve  its  purpose  even  though  its  weight  be  objectionable ;  that  its 
period  of  usefulness  is  limited  and  that  it  must  be  replaced  when  it  is 
outgrown  ;  that  the  breaking  of  a  brace  from  time  to  time  is  unavoid- 
able, and  that  such  accidents,  in  so  far  as  they  are  evidences  of  the 
functional  activity  of  the  patient,  are  favorable  indications. 

Careful  supervision  of  the  patient,  even  though  the  weakness  is  not 
great,  will  be  necessary  during  the  period  of  growth.  The  contrast 
between  the  development  and  symmetry,  the  muscular  power  and  prac- 
tical utility  of  a  limb  that  has  received  this  care  and  supervision,  and 
one  that  has  been  neglected,  is  sufficiently  striking  to  impress  any  one 
with  the  necessity  for  this  tedious  and  apparently  never-ending  treat- 
ment. 

Thus,  in  this  as  in  other  chronic  diseases  and  disabilities,  the  char- 
acter and  the  duration  of  treatment,  its  object  and  the  final  results  that 
one  may  expect  to  attain  by  it,  should  be  explained  to  the  parents  when 
the  care  of  the  patient  is  undertaken. 


CHAPTER    XVIII. 
DISEASES   OF    THE   NERVOUS   SYSTEM.— Contimied. 

CEREBRAL   PARALYSIS   OF    CHILDHOOD. 

Spastic  Paralysis. 

Cerebral  paralysis  or  palsy  is  in  orthopaedic  practice  second  only 
in  frequency  and  importance  to  anterior  poliomyelitis.  It  is  however 
entirely  different  in  its  distribution  and  in  its  effects.  It  is  a  form  of 
disability  that  is  characterized  by  motor  weakness,  by  stiffness  and 
loss  of  control,  rather  than  by  paralysis.  It  affects  entire  members 
and  it  results  in  atrophy,  contractions  and  deformity. 

It  may  involve  half  the  body,  hemiplegia. 

It  may  be  limited  to  the  lower  extremities,  paraplegia. 

It  may  involve  both  the  upper  and  lower  extremities,  diplegia. 

In  rare  instances  but  one  extremity  is  affected,  monoplegia. 

Distribution. — In  452  cases  of  cerebral  paralysis  analyzed  by  Peter- 
son,^ 332  were  of  the  hemiplegic  type,  73  were  of  the  diplegic  type 
and  46  were  of  the  paraplegic  type.  In  121  cases  observed  at  the 
Hospital  for  Ruptured  and  Crippled,  63  were  paraplegic  or  diplegic 
and  58  were  hemiplegic.  The  hemiplegic  form  of  paralysis  is  usually 
acquired ;  the  diplegic  and  paraplegic  forms  are  usually  congenital. 

Etiology  and  Pathology. — Cerebral  paralysis  may  be  divided  into 
two  classes,  the  congenital  and  the  acquired. 

Congenital  Paralysis. — Paralysis  of  intra-uterine  origin  may  be  the 
result  of  mal-development  or  injury  or  a  secondary  effect  of  intercur- 
rent disease  of  the  mother.  Paralysis  caused  by  injury  at  birth  is  usu- 
ally the  result  of  rupture  of  blood  vessels  of  the  meninges  due  to  pro- 
longed labor  or  to  the  pressure  of  instruments. 

Acquired  Paralysis. — Acquired  paralysis  may  be  due  to  hemorrhage, 
embolism  or  thrombosis  or  to  disease.     Sachs  ^  presents  the  following 
classification  of  causes  and  effects. 
Paralysis  of  intra-uterine  origin. 

Large  cerebral  defects — true  porencephaly. 

Hemorrhages  of  intra-uterine  origin.     Softening. 

Agenesis  corticalis. 
Paralysis  occurring  during  labor. 

Meningeal  hemorrhage — very  seldom  intra-cerebral.  Resulting 
conditions  :  meningo-encephalitis  chronica ;  sclerosis  ;  cysts  ;  atro- 
phies ;  porencephalies. 

1  American  Text-book  of  Diseases  of  Children. 
^  Sachs,  The  Nervous  Diseases  of  Children,  1895. 


460 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


Paealysis  acquired  after  birth. 

1.  Meningeal  hemorrhage — very  seldom  intra-cerebral.  Embolism; 
thrombosis  in  marantic  conditions,  and  occasionally  from  syphilitic 
endo-arteritis.  Eesults  of  these  vascular  lesions,  cysts  ;  softening ;. 
atrophy  ;  sclerosis,  diffuse  and  lobar. 

2.  Chronic  meningitis. 

3.  Hydrocephalus. 

4.  Primary  encephalitis  (Striimpell). 


General  Symptoms. 

'     Motor. — The  effect  of  the  lesion  of  the  brain  and  of  the  second- 
ary changes  in  the  cord  is  to  impair  the  voluntary  control  of  the  limbs 

supplied  from  the  affected  area, 
Fig.  319.  and  at  the  same  time  the  inhi- 

bition of  the  higher  centers  is 
impaired  or  lost.  Thus,  together 
with  the  loss  of  power,  there  is 
usually  a  corresponding  exag- 
geration of  the  reflexes  causing 
a  spastic  rigidity  of  the  limbs. 
This  induces  distortion,  which 
finally  becomes  fixed  by  the 
adaptive  changes  in  the  tis- 
sues. As  the  centers  for  the  nu- 
trition of  the  paralyzed  parts 
are  not  involved,  the  muscles  do 
not  waste  and  the  circulation  is 
but  little  affected.  Thus  the 
atrophy  as  compared  with  pa- 
ralysis of  spinal  origin  (anterior 
poliomyelitis)  is  comparatively 
slight,  and  this  together  with 
the  loss  of  growth  is  due  rather 
to  the  general  effects  of  the  dis- 
ease and  to  the  loss  of  function 
than  to  the  direct  influence  of 
the  nervous  lesion. 

Mextal. — In  this  form  of 
paralysis  the  lesion  is  of  the 
brain  and  the  direct  injury  of 
its  structure  or  the  interfer- 
ence with  its  development  is 
likely  to  cause  mental  impairment.  This  mental  impairment  is  usu- 
ally more  marked  in  the  paraplegic  or  diplegic  than  in  the  hemiplegic 
form,  because  in  the  latter  but  half  the  brain  is  involved,  and  because 
the  injury  or  disease  occurs  at  a  later  period  of  its  development.  So 
also  the  mental  development  is  usually  less  interfered  with  in  the  para- 


Congenital  cerebral  diplegia.    Idiocy. 


CONGENITAL  PARALYSIS. 


461 


plegic  than  in  the  diplegic  type.  For  although  both  hemispheres  were 
originally  involved  in  all  probability,  yet  the  recovery  of  power  in  the 
arms  shows  that  the  injury  was  less  extensive  than  when  the  weakness 
persists  in  one  or  both  of  the  upper  extremities. 

It  is  estimated  that  in  50  per  cent,  of  the  hemiplegic  cases  the 
patients  are  feeble-minded,  al- 
though comparatively  few  (13  Fig.  320. 
per  cent.)  are  idiotic.  In  the 
paraplegic  and  diplegic  forms 
of  paralysis  about  70  per  cent, 
of  the  patients  are  feeble-mind- 
ed and  from  40  to  50  per  cent, 
are  idiotic.     (Sachs.) 

Epilepsy  is  an  accompani- 
ment of  about  45  per  cent,  of 
all  forms  of  cerebral  paralysis 
and  in  20  per  cent,  of  the 
cases  athetoid  or  associated 
movements  in  the  paralyzed 
parts  persist.     (Peterson.) 


Congenital  Paralysis. 

The  congenital  form  of  cere- 
bral paralysis  is  often  seen  in 
orthopaedic  clinics,  because  the 
effect  of  the  lesion  of  the  brain 
in  retarding  both  the  mental 
and  physical  development  first 
attracts  the  attention  of  the 
mother.  Thus  infants  are 
brought  for  examination  be- 
cause they  are  unable  to  sit  or 
stand  or  to  talk  at  the  usual 
time.  In  certain  instances  the 
cause  of  the  physical  weakness  spastic  paraplegia. 

is  simple  idiocy.    In  such  cases 

the  vacant  expression,  the  inability  of  the  child  to  recognize  even 
its  mother,  the  extreme  weakness  and  the  absence  of  the  spastic  rigidity 
of  the  limbs,  will  make  the  diagnosis  clear. 

In  another  class  of  cases  the  weakness  appears  to  be  caused  simply 
by  retarded  cerebral  development.  The  patient  is  apathetic  and  weak. 
In  these  cases  also  there  is  no  evidence  of  paralysis,  but  the  evident 
intelligence  of  the  patient  distinguishes  this  type  from  the  idiotic  class. 

In  cerebral  paralysis  the  child  may  be  idiotic,  or  simply  apathetic, 
or  apparently  normal  in  intelligence,  but  it  is  always  weak  and  in  the 
sitting  posture  the  spine  is  usually  bent  backward  into  a  long  more  or 
less  rigid  curve.     It  makes  no  effort  to  stand  and  when  placed  in  the 


462 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


Fig.  321. 


erect  posture  it  will  be  noticed  that  the  thighs  are  usually  pressed 
closely  against  one  another  and  that  the  feet  are  extended.  The  limbs 
are  "  stiff."  There  is  a  peculiar  resistance  to  flexion  at  the  extended 
joints,  which  slowly  gives  way  under  steady  pressure.  This  is  the 
characteristic  spastic  rigidity.      (Fig.  320.) 

Deformities. — These  children  usually  begin  to  stand,  and  to  walk 
at  about  the  third  year  or  later  with  an  awkward  shuflfling  gait ;  the 
limbs  are  usually  flexed,  adducted  and  rotated  inward ;  the  knees 
touch  one  another  or  the  legs  may  be  crossed,  while  the  feet  turn  in- 
ward in  a  persistent  attitude  of  slight  equino-varus.     The  equilibrium 

is  very  easily  disturbed,  partly  because  of 
the  deformities  and  partly  because  of  direct 
lesion  of  the  brain.  In  the  majority  of 
the  congenital  cases  the  paralysis  is  para- 
plegic in  its  distribution ;  perhaps  fifteen 
per  cent,  are  of  the  hemiplegic  variety  and 
in  a  somewhat  larger  number  the  paralysis 
is  diplegic  in  distribution.      (Fig.  319.) 

As  has  been  stated,  in  a  certain  num- 
ber of  cases  the  intelligence  is  not  im- 
paired, but  more  often  the  patients  are  dis- 
tinctly feeble-minded.  They  are  very 
nervous,  easily  startled,  emotional  and  are 
often  unable  to  speak  distinctly,  yet  it  is 
interesting  to  note  that  this  peculiar  emo- 
tional excitability  often  passes  for  an  ex- 
treme degree  of  brightness  of  intellect  and 
quickness  of  perception.  In  fact  parents 
often  remain  unconvinced  that  the  child  is 
lacking  in  mental  power  until  it  reaches  an 
age  when  comparison  with  other  children 
makes  this  conclusion  inevitable. 

Acquired  Paralysis. 

As  in  the  adult  cases  the  common  form 
of  acquired  cerebral  paralysis  in  childhood 
is  hemiplegia.  About  two-thirds  of  all  the 
cases  occur  in  the  first  three  years  of  life  ; 
and  in  about  20  per  cent,  of  the  cases  the 
affection  of  the  brain  is  a  complication  of 
infectious  disease.  The  onset  is  usually  sud- 
den and  is  accompanied  in  the  majority  of 
the  cases  by  fever,  convulsions  and  loss  of 
consciousness.  When  the  child  regains 
consciousness  the  paralysis  of  the  arm  and  leg  is  at  once  evident,  and 
in  about  20  per  cent,  of  the  cases  the  face  is  paralyzed  also. 

Deformities. — At  first  the  paralysis  is  a  simple  powerlessness,  but 


*■  Acquired  cerebral  hemiplegia. 


TREATMENT  OF  HEMIPLEGIA.  463 

soon  the  exaggeration  of  the  reflexes  is  evident.  As  has  been  stated, 
there  i^  a  loss  of  voluntary  power  and  an  increase  of  the  reflexes  or 
stiffness  of  the  paralyzed  members.  They  are  no  longer  competent  to 
assume  the  more  difficult  attitudes  and  functions,  and  these  are  replaced 
by  those  that  are  simpler  ;   thus  flexion  becomes  habitual. 

In  typical  hemiplegia  the  foot  is  plantar-flexed  and  adducted.  The 
leg  is  flexed  on  the  thigh  and  the  thigh  on  the  trunk,  and  with  the 
flexion,  adduction  is  usually  combined.  The  arm  is  held  against  the 
body,  the  forearm  is  flexed  upon  the  arm  in  an  attitude  midway  be- 
tween pronation  and  supination.  The  hand  is  flexed  upon  the  arm 
and  inclined  toward  the  ulnar  side  and  the  fingers  are  clasped  over  the 
adducted  thumb. 

Disability. — The  loss  of  power  is  not  absolute  ;  in  most  instances 
the  patient  is  able  to  walk  with  an  exaggerated  limp,  dragging  the 
stiffened  and  contracted  leg  which  serves  as  a  prop  rather  than  as  an 
active  support.  So  also  the  control  of  the  upper  extremities  is  in  part 
retained ;  the  patient  is  able  to  abduct  the  arm,  to  partly  extend  the 
forearm,  sometimes  to  extend  the  fingers  and  to  abduct  the  thumb,  but 
the  power  to  dorsi-flex  the  hand  and  at  the  same  time  to  extend  the 
fingers  is  not  usually  retained  in  a  case  of  this  character. 

Loss  OF  Geowth. — The  growth  of  the  patient  as  a  whole  is  usually 
retarded,  and  checked  to  a  certain  extent,  by  the  lesion  of  the  brain. 
There  is  in  addition  a  certain  degree  of  inequality  in  the  growth  of  the 
two  halves  of  the  body.  This  inequality  is  more  marked  in  the  arms 
than  in  the  legs.  Shortening  to  the  extent  of  an  inch  in  the  lower  ex- 
tremity is  not  often  exceeded,  but  the  growth  of  the  arm  and  hand  may 
be  very  markedly  checked.  This  disproportionate  loss  of  growth  in 
the  upper  over  the  lower  extremity,  although  it  may  be  explained  in 
part  by  the  situation  of  the  lesion  of  the  brain,  depends  more  directly 
upon  the  interference  with  function.  The  lower  extremity  is  rarely 
disabled  to  an  extent  that  prevents  its  use  in  locomotion,  consequently 
its  nutrition  is  preserved,  whereas  the  same  degree  of  paralysis  of  the 
arm  utterly  unfits  it  for  its  more  difficult  functions  and  it  becomes  a 
useless  appendage.  With  the  disuse  of  function  there  is  a  correspond- 
ing diminution  of  nutrition  and  a  consequent  atrophy  and  loss  of  growth. 

Extreme  deformity  and  disability,  as  in  the  type  described,  is  rather 
unusual.  In  many  instances  there  is  almost  complete  recovery  from 
the  paralysis,  only  an  awkwardness  and  slowness  of  movement,  com- 
bined with  an  increase  of  reflexes  and  a  slight  hemiatrophy  of  the 
body  persists.  In  some  cases  a  slight  degree  of  equinus  is  the  only 
deformity ;  in  others  weakness  of  the  arm  may  persist  although  com- 
plete control  of  the  lower  extremities  has  been  regained. 

The  final  effect  of  the  paralysis  is  almost  always  more  marked  in 
the  upper  than  in  the  lower  extremity ;  thus  when  contractions  and 
deformities  of  the  lower  extremity  are  present  the  arm  and  hand  are 
often  practically  disabled. 

Treatment.  1 .  Hemiplegia. — The  treatment  from  the  orthopaedic 
standpoint  consists  in  stimulating  the  nutrition  of  the  paralyzed  parts, 


464  DISEASES  OF  THE  NERVOUS  SYSTEM. 

in  preventing  deformity  and  in  improving  the  functional  ability.  The 
results  of  treatment  are,  of  course,  very  greatly  influenced  by  the 
mental  condition  of  the  patient.  If  the  mental  power  is  not  impaired 
one  may  count  upon  the  eiforts  of  the  patient  to  aid  the  surgeon, 
whereas  if  the  patient  is  idiotic  there  is  but  little  encouragement  for 
active  treatment.  If  the  patient  is  seen  before  the  secondary  contrac- 
tions have  appeared,  deformity  may  be  prevented  in  great  degree  by 
regular  massage  and  by  passive  movements  in  the  directions  opposed 
to  the  habitual  positions.  If  the  spastic  rigidity  is  slight  the  control 
of  the  movements  of  the  leg  may  be  made  easier  by  the  use  of  a  light 
jointed  leg  brace  attached  to  a  pelvic  baud.  By  this  means  the  move- 
ments are  controlled  and  the  excessive  expenditure  of  nervous  energy 
necessary  to  guide  the  limb  may  be  lessened.  This  support  should  be 
supplemented  by  massage  and  exercise,  and  in  the  milder  type  of 
paralysis  the  control  of  the  limb  may  be  greatly  improved. 

In  many  instances  the  patients  are  not  seen  until  late  childhood, 
when  the  deformities  have  become  fixed.  The  foot  is  nsually  turned 
inward  and  downward  (equino-varus),  there  is  flexion  at  the  knee  and 
often  flexion  and  adduction  at  the  hip,  the  resistance  of  the  contractions 
being  dependent  upon  the  duration  of  the  deformity.  In  such  cases 
the  distortions  must  be  corrected  by  force  and  by  division  of  more  re- 
sistant tissues  including  often  the  tendo  Achillis,  the  plantar  fascia, 
and  in  many  instances  the  hamstrings,  and  the  adductors  of  the  hip. 
The  limb  is  then  fixed  in  a  plaster  of  Paris  bandage  for  a  sufficient 
time  to  overcome  the  more  direct  tendency  to  deformity.  When  the 
bandage  is  removed  a  brace  is  of  service  in  guiding  the  limb,  and 
regular  massage  and  forcible  passive  movements  together  with  proper 
exercises  should  be  employed  whenever  practicable.  In  this  class  of 
cases  the  deformities  may  be  overcome  in  most  instances,  but  there  is 
a  tendency  toward  flexion  at  the  knee,  and  stiffness  and  awkward- 
ness in  movement  usually  persist. 

In  many  of  the  milder  hemiplegic  cases  the  only  deformity  is  of  the 
foot.  This  should  be  treated  by  division  of  the  tendo  Achillis  and  by 
support  for  a  time  until  the  deformity  habit  has  disappeared. 

If  the  arm  is  but  slightly  affected  proper  exercises  will  greatly  im- 
prove its  ability.  In  the  more  extreme  cases  in  which  the  fingers  are 
clasped  over  one  another,  treatment  is  practically  useless.  In  the  third 
class  in  which  the  patient  has  the  power  of  extending  the  fingers  only 
when  the  wrist  is  flexed,  the  power  of  dorsi-flexion  may  be  restored 
or  improved  by  transplanting  the  flexors  of  the  carpus  on  the  radial 
and  ulna  border  to  the  extensors  which  have  been  over-lapped  and 
shortened  to  the  proper  extent.  The  transplantation  of  other  tendons 
may  be  of  service,  but  the  operation  is  limited  in  usefulness  for  the 
reasons  stated.^  Athetoid  movements  of  the  hand  and  arm  niay  be 
relieved  somewhat  by  prolonged  fixation  in  a  plaster  bandage,  or  by 
arthrodesis  at  the  wrist  joint. 

2.  Paraplegia. — The  treatment  of  spastic  paraplegia  is  much  more 

iTownsend,  Trans.  Am.  Orth.  Ass'n,  Vol.  XIII.,  1900. 


TREATMENT  OF  PARAPLEGIA. 


465 


difficult   than   that  of  hemiplegia  because  the  disability  is  very  much 
greater-and  because  the  mental  impairment  is  usually  more  marked. 

In  general  the  treatment  in  infancy  is  by  massage  and  by  manipula- 
tion. When  the  child  shows  a  desire  to  walk  an  attempt  should  be 
made  to  relieve  the  spastic  contractions.  In  certain  instances  complete 
correction  of  all  deformities,  followed  by  prolonged  fixation  of  each  joint 
in  the  over-corrected  attitude,  may  be  of  service.     (Fig.  322.)     This 

Fig.  322. 


Cerebral  paraplegia,  second  stage  iu  treatiueut.  The  long  replaced  by  the  short  sisica.  This  pa- 
tient at  the  age  of  eight  years  was  unable  to  stand  without  assistance.  The  spastic  contractions  and 
deformities  were  overcome  by  tenotomies  and  by  force,  and  a  double  long  spica  bandage  was  applied. 
This  was  worn  for  eight  months.  It  was  then  replaced  by  the  bandage  shown  iu  illustration.  Six 
months  later  this  was  removed.    There  is  at  present  no  deformity,  and  the  child  walks  fairly  well. 


may  be  combined  with  multiple  tenotomies  if  the  contractions  are  more 
resistant.  The  advantage  of  tenotomy,  aside  from  the  simple  correction 
of  deformity,  is  that  by  elongation  of  the  tendon  the  response  to  the 
exaggerated  motor  impulses  is  lessened  and  an  opportunity  for  more 
effective  control  is  afforded.  Transplantation  of  tendons  from  the 
flexor  to  the  extensor  aspect  of  the  limb  has  been  performed  in  several 
instances  but  the  value  of  the  procedure  is  still  in  doubt.  Except  in  the 
very  mild  cases  of  paraplegia,  braces  are  of  little  value.  The  trunk  is 
30 


466  DISEASES  OF  THE  NERVOUS  SYSTEM. 

not  as  a  rule  deformed  except  in  the  diplegic  cases  in  which  the  mental 
impairment  is  great.  Manipulation,  massage  and  posture  are  of  some 
service  in  correcting  and  preventing  this  distortion. 

Prognosis. — It  is  stated  by  Peterson  ^  that  the  patients  in  whom  the 
paralysis  is  paraplegic  or  diplegic  usually  die  before  the  twentieth 
year,  and  that  but  few  of  those  in  whom  it  is  hemiplegic  reach  the  age 
of  forty.  This  prognosis  applies,  it  may  be  assumed,  rather  to  the 
extreme  cases  accompanied  by  mental  impairment  than  to  the  milder 
forms.  In  almost  all  cases  the  patient  even  if  idiotic  is  finally  able 
to  stand  and  to  walk.  As  a  rule  there  is  for  a  time  a  gradual  im- 
provement in  motor  power  and  in  mental  control  as  well.  It  is  evident 
that  in  a  class  in  which  mental  enfeeblement  is  so  common  and  in 
which  epilepsy  is  present  in  so  large  a  proportion  of  cases,  simple  care 
and  moral  and  mental  training  are  of  great  importance. 

Orthopaedic  treatment,  although  it  has  no  direct  action  upon  the  le- 
sion in  the  brain,  certainly  has  an  indirect  efi'ect  upon  the  mental  as 
well  as  upon  the  physical  condition  of  the  patient.  When  deformity 
has  been  corrected  and  when  contractions  have  been  overcome,  func- 
tional use  requires  less  mental  effort ;  and  motor  control  may  be  still 
further  improved  by  drilling  the  patient  constantly  in  simple  move- 
ments. Such  exercises  improve  the  motor  communications  and  the 
ability  of  the  paralyzed  part  as  well. 

Progressive  Muscular  Atrophy. 

Progressive  muscular  atrophy,  as  the  term  implies,  is  a  progressive 
wasting  of  the  muscles,  with  corresponding  loss  of  power,  terminating 
finally  in  paralysis  and  deformity. 

Under  this  title  are  included  two  varieties  of  disease. 

1.  The  myelopathic  form  in  which  there  is  primary  disease  of  the 
spinal  cord.. 

2.  The  myopathic  form  in  which  the  disease  is  primarily  of  the 
nerve  terminals  and  the  muscular  fibers. 

The  second  variety  is  usually  designated  as  muscular  dystrophy  to 
distinguish  it  from  the  spinal  form. 

Myelopathic  Paralysis  or  Atrophy. — The  myelopathic  form 
of  muscular  atrophy,  the  Aran-Duchenne  type,  usually  begins  in  the 
small  muscles  of  the  hands  and  spreads  from  the  periphery  to  the 
trunk.  Fibrillary  twitching  of  the  affected  and  unaffected  muscles 
is  fairly  constant  and  the  reaction  of  degeneration  may  be  present. 
The  disease  is  practically  limited  to  adults  and  from  the  orthopsedic 
standpoint  it  is  of  little  interest.  In  another  form,  the  Charcot-Marie- 
Tooth  type,  usually  classed  with  the  muscular  atrophies,  the  paralysis 
may  begin  in  the  muscles  of  the  legs,  causing  deformity  of  the  equinus 
or  equino-varus  variety.  The  lesion  of  the  cord  in  muscular  atrophy 
is  of  the  anterior  cornua,  and  resembles  closely  that  of  the  subacute 
form  of  anterior  poliomyelitis. 

•Trans.  Am.  Orth.  Ass'n,  Vol.  XIIL,  1900. 


MUSCULAR  DYSTROPHY. 


467 


Myopathic  Paralysis  or  Muscular  Dystrophy. — The  myo- 
pathic form  of  muscular  atrophy  may  be  preceded  by  apparent  hyper- 
trophy (pseudo-hypertrophic  muscular  paralysis),  it  may  be  primarily 
atrophic,  or  the  two  forms  may  be  combined. 

It  differs  from  the  myelopathic  form  in  several  particulars.      It  is  a 
disease  of  childhood.    It  is  often  heredi- 
tary and  its  distribution  is  different. 

The  affection  is  divided  according  to 
the  distribution  into  two  main  varieties. 

Fig.  323. 


Fig.  324. 


Progressive  muscular  dys- 
trophy, showing  the  enlargement 
of  the  calves  and  the  atrophy  of 
the  shoulder  muscles. 


Prdniessivc  luuscular  dystro- 
phy, facio-scapulo-humeral  type. 
Extreme  lordosis  and  flexion  con- 
tractions at  the  hips. 


1.  The  facio-scapulo-humeral  type  (Landouzy-Dejerine),  in  which 
the  muscles  of  the  face  and  shoulder  girdle  are  primarily  affected. 
(Fig.  324.) 

2.  The  juvenile  form  of  Erb,  in  which  the  muscles  of  the  back  and 
of  the  upper  arms  are  first  involved. 


468  DISEASES  OF  THE  NERVOUS  SYSTEM. 

The  etiology,  pathology  and  clinical  course  of  the  atrophic  does  not 
diifer  essentially  from  the  pseudo-hypertrophic  form. 

PSEUDO-HYPERTROPHIC     MuSCULAR     PARALYSIS. Pseudo-hyper- 

trophic  paralysis  is  characterized  by  progressive  weakness  of  the  mus- 
cles of  the  trunk  and  of  the  legs  associated  with  apparent  hypertrophy 
of  the  calv^es  due  to  a  deposit  of  fat  in  the  wasting  muscles.     (Fig.  323.) 

The  symptoms  are  caused  by  a  degenerative  atrophy  of  the  nerve 
terminals  and  of  the  muscular  fibers  and  an  increase  of  the  connective 
tissue  and  replacement  of  the  muscular  substance  by  fat. 

Diagnosis. — The  interest  in  this  latter  affection  from  the  orthopaedic 
standpoint  lies  in  the  diagnosis  in  the  early  stage  of  the  affection.  At 
this  time  the  patient  is  evidently  weak,  he  walks  with  an  awkward, 
shambling  gait  and  climbing  stairs  is  especially  difficult.  There  is 
usually  an  increased  lordosis  and  a  peculiar  swaying  or  waddle,  a  disin- 
clination to  stoop  and  an  evident  difficulty  in  regaining  the  erect  pos- 
ture, and  there  may  be  discomfort  or  pain  referred  to  the  lumbar  region. 
If  the  disease  is  advanced,  the  peculiar  hard,  resistant  enlargement  of 
the  calves,  combined,  it  may  be,  with  atrophy  of  the  muscular  groups  of 
the  upper  extremity,  and  weakness  of  the  muscles  of  the  back,  makes 
the  diagnosis  evident,  but  in  young  children  the  disease  may  be  mis- 
taken for  Pott's  disease,  simple  weakness,  or  postural  deformity.  Al- 
though there  is  a  superficial  resemblance  to  the  general  symptoms  of 
Pott's  disease,  yet  the  specific  signs  of  disease  of  the  vertebrae,  pain  and 
muscular  spasm,  are  absent. 

Weakness,  a  result  of  malnutrition  or  disease,  is  general  in  char- 
acter and  its  cause  is  usually  apparent ;  it  is,  of  course,  not  accom- 
panied by  local  hypertrophy.  Retarded  cerebral  development  causes 
general  weakness  as  far  as  inability  to  stand  is  concerned,  but  the  cause 
is  in  this  class  also  usually  apparent.  Postural  deformities  in  child- 
hood always  have  a  cause,  and  as  one  is  not  content  to  treat  a  deformity 
without  ascertaining  its  cause,  this  search  will  bring  to  light  the  pecu- 
liar symptoms  of  the  disease. 

Treatment. — In  certain  instances  the  discomfort  referred  to  the 
back,  due  in  part  to  the  lordosis,  may  be  relieved  by  a  light  spinal  sup- 
port. Massage  and  muscle  training  may  enable  the  patient  to  utilize 
the  remaining  power  to  best  advantage. 

In  the  later  stages  of  the  disease  there  may  be  secondary  deformities, 
most  marked  in  the  feet  which  may  be  fixed  in  the  equinus  or  equino- 
varus  attitude.  This  deformity  may  be  corrected  by  tenotomy  or  other- 
wise, if  the  patient  has  not  already  become  so  weak  that  walking  or 
standing  is  impossible. 

Hereditary  Ataxia.     Friedreich's  Disease. 

Hereditary  ataxia  is  an  ataxic  paraplegia  caused  by  sclerosis  of  the 
posterior  and  lateral  columns  of  the  spinal  cord.  The  early  symptoms 
are  incoordination  and  weakness  of  the  legs;  later  similar  symptoms  ap- 
pear in  the  upper  extremities  and  speech  is  affected.     In  well-marked 


''HYSTERICAL  HIP."  469 

cases  there  is  usually  distortion  of  the  feet  toward  equinus  or  equino- 
varusj  gind  occasionally  a  posterior  or  lateral  curvature  of  the  spine.  In 
one  case  recently  under  treatment  at  the  Hospital  for  Ruptured  and 
Crippled,  the  rectification  of  the  deformity  of  the  feet  was  at  least  of 
temporary  benefit. 

Neuritis. 

Localized  neuritis  after  contagious  disease  or  from  other  causes  may 
result  in  temporary  weakness  or  paralysis  of  the  dorsal  flexors  of  the 
foot,  cause  toe  drop  and  finally  deformity.  In  such  cases  the  foot  should 
be  supported  by  a  brace  in  normal  position.  This  not  only  prevents 
deformity,  but  it  hastens  the  cure  by  preventing  tension  upon  and  struc- 
tural lengthening  of  the  weakened  muscles.  The  same  treatment  may 
be  applied  for  wrist  drop  from  metallic  poisoning.  The  hand  should 
be  supported  by  a  suitable  brace  in  the  attitude  of  dorsi-flexion  until 
the  muscles  have  recovered  their  power.  Obstetrical  paralysis  has  been 
considered  under  affections  of  the  shoulder. 


Hysterical  Joint  Affections  and  Deformities. 
Functional  Affections  of  the  Joints. 

So-called  hysterical  or  functional  affections  may  be  divided  into  two 
groups. 

1.  Those  in  which  there  is  no  actual  disease  or  weakness. 

2.  Those  in  which  the  symptoms  of  disease  or  injury,  or  of  their 
effects,  are  exaggerated  and  prolonged. 

The  first  class  of  cases  is  small,  the  second  is  large. 

Simulation,  whether  voluntary  or  involuntary,  of  organic  disease  can 
deceive  only  those  who  are  not  familiar  with  the  characteristics  of  the 
disability  that  is  simulated.  Every  disease  has  certain  well-defined 
symptoms  which  can  no  more  be  imitated  by  a  well  person  than  a  dis- 
abled part  can  suddenly  take  on  the  normal  appearance  and  function. 

"Hysterical   Hip." 

The  hysterical  hip  is  supposed  to  simulate  actual  tuberculous  disease. 

Diagnosis. — The  symptoms  of  actual  disease  of  this  joint  are  pain, 
limp,  limitation  of  motion  due  to  reflex  muscular  spasm,,  muscular 
atrophy,  distortion  and  in  the  later  stages  the  local  signs  of  a  destructive 
process  ;  for  example,  heat,  swelling,  abscess  and  displacement  of  the 
parts,  shortening  of  the  limb  and  the  like.  As  these  later  symptoms 
could  not  be  simulated  they  need  not  be  considered. 

In  actual  disease  symptoms  and  effects  follow  one  another  in  regular 
sequence  and  correspond  closely  to  the  pathological  conditions  that 
cause  them.  Pain  is  not  a  pronounced  symptom  ;  it  is  more  likely  to 
be  concealed  than  exaggerated  and  it  is  usually  referred  to  the  knee. 
Local  sensitiveness  is  not  a  pronounced  symptom,  and  it  is  often  absent. 
Distortion  of  the  limb  when  it  occurs  in  the  early  stage,  before  the  de- 


470  DISEASES  OF  THE  NERVOUS  SYSTEM. 

structive  changes  are  advanced,  is  caused  by  reflex  muscular  spasm 
and  whenever  this  distortion  is  great  the  reflex  muscular  spasm,  which 
involves  every  muscle  about  the  joint,  is  also  great ;  so  that  the  range 
of  motion  in  the  joint  is  small,  and  motion  may  be  absolutely  prevented. 
With  the  distortion  there  is  always  a  corresponding  atrophy  of  the 
muscles  of  the  limb.  If  pain  is  present  it  is  usually  worse  at  night 
than  during  the  day. 

The  hysterical  simulation  of  hip  disease  is  characterized  by  an  ex- 
aggeration of  the  symptoms  and  by  absence  of  the  physical  signs  of 
disease.  There  is  usually  an  exaggerated  limp,  great  distortion, 
marked  local  sensitiveness  and  pain,  but  absence  of  muscular  spasm, 
atrophy  or  other  signs  of  disease. 

The  essential  differences  between  actual  disease  and  its  simulation 
may  be  presented  more  effectively  by  contrasting  them. 

Disease.  Simulated  Disease. 

Pain,  intermittent  or  absent  or  Patient  often  complains  bitterly 

concealed  ;  referred  to  the  knee,  of  pain,  referred  to  the  hip  or  to  the 
Often  worse  at  night.  entire  limb.  Worse  during  the  day. 

Local  sensitiveness,  often  absent  Often  extreme,  caused  by  the 

or  caused  only  by  deep  pressure.        slightest  manipulation  ;    the  skin 

is  hypersesthetic. 

Limp,  corresponds  to  the  acute-  Exaggerated,    does    not    corre- 

ness  of  the  symptoms  or  to  the  dis-     spond  to  the  physical  signs,  may 
tortion  ;  slight  iu  the  early  stage,      be  intermittent, 
but  constant. 

Distortion,  slight  in  the   early  Often  great  in  the  early  stage, 

stage,  is  dependent  on  the  degree     bears  no  relation  to  the  physical 
of  muscular  spasm  and  upon  the     signs  ;  is  intermittent,  may  disap- 
quality  of  the  disease  ;  is  constant     pear  at  night ;  can  be  reduced  by 
and  cannot  be  reduced  by  manipu-     manipulation, 
lation. 

Muscular  spasm,  always  present.  Absent. 

Muscular  atrophy,  always  pres-  Slight  or  absent, 

ent. 

Local  signs  of  a  destructive  dis-  Absent. 

ease,  often  apparent  at  an  early 
stage. 

The  age  of  the  patient,  the  history  of  the  supposed  disease  and  the 
other  evidences  of  hysteria  that  are  usually  present,  will  confirm  the 
diagnosis. 

The  same  principle  applies  of  course  to  the  differential  diagnosis  of 
simulated  disease  at  other  joints.  The  knee  and  the  hip  are  those  that 
are  most  often  involved. 

Hysterical  Deformities. 

"  Hysterical  Club  Foot." — Local  deformity  distinct  from  simulated 
joint  disease   is  sometimes   seen.     Several  cases  of  this  character  in 


''NEUROTIC  JOINTS."  471 

which  the  foot  was  distorted  have  been  under  treatment  at  the  Hospital 
for  Ruptured  and  Crippled,  recently.  The  diiferential  diagnosis  is 
simple. 

Talipes  is  either  congenital  or  acquired.  Congenital  talipes  and  all 
the  acquired  varieties,  other  than  those  of  paralytic  origin,  may  be  at 
once  excluded  from  consideration.  Paralytic  talipes  in  the  vast  ma- 
jority of  cases  begins  in  early  childhood  when  it  is  either  caused  by 
anterior  poliomyelitis  or  is  one  of  the  deformities  of  cerebral  hemiplegia 
or  paraplegia.  When  these  are  excluded,  the  remaining  causes  of  de- 
formity are  very  limited.  Every  variety  of  nervous  disease  has  well- 
defined  symptoms.  If  actual  paralysis  is  present  the  muscles  atrophy 
and  the  electrical  reactions  are  changed.  In  hysterical  contractions  the 
muscles  do  not  atrophy  and  the  electrical  reactions  are  unchanged. 

"  Hysterical  Scoliosis." — A  case  was  recently  under  observation  at 
the  Hospital  for  Ruptured  and  Crippled,  in  which  distortion  of  the 
trunk  persisted  for  more  than  a  year,  and  until  a  suit  for  damages  was 
finally  decided.  In  this  case  there  was  a  most  exaggerated  lateral 
twist  of  the  spine  so  that  the  shoulder  approached  the  pelvis.  The 
deformity  however  was  not  fixed,  but  it  could  be  completely  reduced 
when  the  patient  was  in  the  recumbent  posture.  There  was  no  par- 
alysis, no  persistent  spasm,  no  evidence  of  disease  or  injury.  The  de- 
formity was  of  a  nature  that  could  not  be  explained  by  any  conceivable 
lesion,  and  all  the  signs  of  hysteria  were  present. 

Treatment. — The  principles  of  the  treatment  of  pronounced  hys- 
teria of  which  simulated  joint  disease  or  deformity  are  but  unusual  man- 
ifestations are  considered  at  length  in  medical  and  neurological  works, 
and  the  subject  does  not  call  for  especial  mention  here.  It  is  evident, 
of  course,  that  an  unequivocal  diagnosis  must  be  the  first  and  essential 
step  toward  cure.  In  this  class  of  cases  apparatus  is  not  often  indi- 
cated unless  the  deformity  has  persisted  for  so  long  a  time  that  the  dis- 
used muscles  have  become  incapable  of  performing  their  proper  functions. 


FUNCTIONAL  AFFECTIONS  OF  THE  JOINTS. 
"Neurotic  Joints." 

In  this  class,  although  there  is  no  absolute  distinction  between  it 
and  the  preceding  variety,  there  is  usually  a  physical  basis  for  the 
symptoms,  however  much  they  may  be  exaggerated. 

The  patients  are  not  usually  hysterical,  in  fact  hysteria  in  the  ordi- 
narily accepted  sense  is  uncommon,  and  although  the  larger  proportion 
of  patients  are  women,  yet  men  and  children  are  by  no  means  exempt 
from  the  so-called  functional  aifections. 

It  must  be  borne  in  mind  also  that  many  of  these  cases  are  classed 
as  neurotic  simply  because  the  cause  of  the  symptoms  is  not  apparent. 
It  is  only  within  a  few  years  that  the  slighter  degrees  of  weak  foot 
and  its  effects  have  been  recognized,  and  it  is  probable  that  such  cases, 
together  with  anterior  metatarsalgia,  the  painful  fascia  of  the  con- 


472  DISEASES  OF  THE  NERVOUS  SYSTEM. 

tracted  foot,  achillodynia  and  the  like  might  be  considered  as  neurotic 
by  one  unfamiliar  with  their  symptoms.  And  it  may  be  inferred  that 
as  diagnosis  becomes  more  accurate  the  more  restricted  will  become 
the  class  of  cases  of  purely  imaginary  disability,  in  so  far  at  least  as 
the  locomotive  apparatus  is  concerned. 

A  "  neurotic  joint "  is  often  caused  by  injury.  A  sprain  of  the  ankle, 
for  example,  may  have  been  treated  by  prolonged  immobilization,  either 
because  the  patient  had  originally  impressed  the  physician  with  the 
severity  of  the  symptoms  or  because  of  persistent  discomfort.  When 
the  dressing  is  removed  there  may  be  congestion  and  discoloration  due 
to  impaired  circulation,  weakness  and  atrophy  of  the  muscles  due 
simply  to  disuse,  and  a  certain  degree  of  infiltration  and  stiffness  caused 
by  the  original  injury.  In  cases  of  this  character  the  disability  may 
be  prolonged  because  the  patient  or  the  physician  mistakes  the  effects 
of  disuse  for  the  symptoms  of  serious  injury  or  disease.  When  the 
diagnosis  has  been  made  treatment  should  be  directed  to  increasing 
the  activity  of  the  circulation  and  thus  the  nutrition  of  the  part,  by 
counter-irritation,  by  massage,  by  passive  movements,  by  voluntary 
exercises  and  the  like,  but  cure  can  only  be  completed  by  restoring 
functional  use.  If,  therefore,  the  disability  is  of  long  standing  a  tem- 
porary brace  will  be  required  to  protect  the  part  from  injury,  and  to 
increase  the  patient's  confidence.  In  milder  cases  it  is  possible  that 
without  support  or  treatment,  other  than  an  assurance  of  the  absence  of 
serious  weakness,  cure  may  be  accomplished,  but  this  is  certainly  unusual. 

What  has  been  said  of  exaggerated  disability  at  the  ankle  following 
traumatism,  applies  to  the  treatment  of  similar  affections  elsewhere. 
The  knee-joint  is  very  often  the  seat  of  so-called  neurosis.  Injury 
at  this  point  in  nervous  children  is  often  followed  by  a  persistent 
flexion  contraction  that  may  continue  for  weeks  after  all  signs  of  the 
injury  have  disappeared.  When  the  attempt  is  made  to  straighten  the 
knee  the  patient  screams  with  pain  and  the  muscular  resistance  is  very 
great.  In  such  cases  the  immediate  rectification  of  deformity  and  the 
application  of  a  plaster  bandage  to  hold  the  limb  in  the  corrected 
position  is  indicated.  It  must  be  borne  in  mind  that  the  persistent 
assumption  of  a  deformed  position  for  weeks  or  months  must  be  fol- 
lowed by  certain  structural  changes  in  the  contracted  muscles  and 
weakness  in  the  opposing  groups.  Thus  some  assistance  may  be 
required  in  the  treatment  even  of  the  purely  hysterical  deformities,  be- 
cause of  this  weakness. 

In  all  forms  of  traumatic  neurosis,  so  called,  the  possibility  of  a 
physical  basis  for  the  symptoms  should  be  considered,  the  location  of 
the  pain  or  discomfort  and  its  connection  with  certain  movements  or 
attitudes  should  be  investigated.  If  such  discomfort  is  induced  or  is 
aggravated  always  by  a  certain  motion  or  attitude  it  is  reasonable  to  infer 
that  this  has  a  well-defined  cause,  especially  as  the  pain  of  a  neurotic 
affection  is  not  often  of  this  definite  character.  In  this  class  of  cases 
limitation  of  movement  for  a  time  to  the  painless  range  of  motion  by 
some  form  of  support  may  be  indicated. 


''NEUROTIC  JOINTS."  473 

Thus  far  injury  has  been  considered  as  the  starting  point  of  the 
symptoias,  but  in  many  cases  there  is  no  history  of  injury.  In  this 
class  the  symptoms  may  have  been  induced  by  rheumatism  or  gout  or 
rheumatoid  arthritis,  or  by  neuritis  and  such  possible  causes  should  be 
investigated  and  excluded  before  the  diagnosis  of  simple  neurosis  is 
made.  In  neurasthenic  patients  or  those  who  are  anaemic,  or  over- 
worked, the  pain  and  discomfort  is  often  localized  in  the  spine.  The 
"  neurotic  spine  "  has  been  considered  elsewhere.  In  the  treatment 
of  all  cases  of  this  group  the  general  condition  of  the  patient  should 
receive  consideration,  and  in  connection  with  the  local  treatment  a 
change  of  occupation  and  of  scene  is  often  of  advantage. 

It  is  hardly  necessary  to  insist  again  that  an  accurate  diagnosis  is 
the  first  essential  of  successful  treatment.  If  this  is  impossible,  at 
least  one  may  by  exclusion  of  those  injuries  and  disabilities  and  dis- 
eases which  are  evidently  not  present,  arrive  at  a  general  conclusion  as 
to  the  character  of  the  ailment,  and  shape  his  treatment  accordingly. 


CHAPTER   XIX. 
CONGENITAL   AND   ACQUIRED    TORTICOLLIS. 

Torticollis. 

Synonym. — Wry  Neck. 

Torticollis  is,  as  the  name  implies,  a  twisted  neck ;  a  distortion 
caused  in  most  instances  by  active  contraction  or  by  shortening  of  one 
or  more  of  the  lateral  muscles  that  control  the  head.  Similar  distor- 
tion may  be  due  to  disease  of  the  spine,  so-called  false  torticollis,  but 
this  should  be  classed  as  a  symptom  of  the  underlying  disease,  not  as 
simple  torticollis  of  which  the  distortion  itself  is  the  important  dis- 
ability that  demands  treatment. 

Torticollis  may  be  divided  primarily  into  two  classes,  the  congenital 
and  the  acquired. 

Congenital  torticollis  is  a  painless  shortening  of  the  tissues  on  one 
side  of  the  neck,  of  intra-uterine  origin. 

Acquired  torticollis  is,  in  most  instances,  accompanied  in  its  early 
stages  by  local  pain  and  sensitiveness,  and  by  active  contraction  of  the 
affected  muscles.  After  a  time  these  acute  symptoms  disappear  leaving 
simply  the  deformity.  Thus  from  the  therapeutic  standpoint,  torti- 
collis may  be  classified  as  acute  and  chronic,  the  latter  class  includ- 
ing the  congenital  form. 

The  sterno-mastoid  is  the  muscle  that  is  usually  involved  primarily, 
both  in  the  congenital  and  acquired  forms ;  thus  in  typical  torticollis, 
the  head  is  drawn  somewhat  forward  and  is  inclined  toward  the  con- 
tracted muscle  while  the  chin  is  slightly  elevated  and  turned  toward 
the  opposite  shoulder,  an  attitude  explained  by  the  normal  action  of 
the  affected  muscle.  Irregular  distortions  of  the  head,  as  posterior  or 
anterior  torticollis  due  to  contraction  of  muscles  other  than  the  sterno- 
mastoid,  are  however  not  infrequent.  These  will  be  mentioned  in  the 
consideration  of  the  forms  of  acquired  torticollis. 

Statistics. — Torticollis  is  comparatively  an  uncommon  deformity. 
In  a  period  of  twenty-seven  years  507  cases  were  treated  at  the  Hos- 
pital for  Ruptured  and  Crippled  as  contrasted  with  upwards  of  5,000 
cases  of  congenital  and  acquired  talipes. 

Acquired  torticollis  is  by  far  the  more  common  variety  as  is  shown 
by  the  fact  that  of  the  507  cases  but  87  were  supposed  to  be  of  con- 
genital origin. 

It  is  often  stated  that  torticollis  is  more  common  in  males  than  in 
females,  and  that  the  right  side  is  more  often  affected,  yet  46  of  the  87 
congenital  cases  were  in  females  and  the  contraction  was  of  the  left 
side  in  38  of  the  58  cases  in  which  the  affected  side  ^vas  specified.    Of 


CONGENITAL   TORTICOLLIS. 


475 


the  entire  number  of  cases  available  for  comparison  246  were  in  fe- 
males and  198  in  males  ;  in  236  instances  the  contraction  was  on  the 
left  and  in  196  on  the  right  side  of  the  neck.  From  these  statistics 
it  would  appear  that  the  deformity  is  somewhat  more  common  in  fe- 
males than  in  males  and  that  the  left  side  is  more  often  affected  than 
the  right. 

Congenital  Torticollis. 

In  most  instances  the  deformity  of  congenital  torticollis  is  slight  at 
birth  and  it  may  not  attract  attention  until  the  child  sits  or  walks 
even.  Thus  it  is  often  difficult  to  distinguish  the  congenital  form  from 
the  deformity  that  may  have  been  acquired  in  infancy,  especially  as  the 

Fig.  .32.5. 


Left  torticollis  apparently  of  congenital  origin,  sliowiug  the  secondary  distortions  of  head  and  face. 


patient  may  not  be  brought  for  treatment  until  the  distortion  has  per- 
sisted for  many  years. 

In  early  infancy  slight  torticollis  may  be  demonstrated  by  holding 
the  arm  on  the  affected  side  and  drawing  the  head  forcibly  in  the  op- 
posite direction,  when  the  shortened  muscle  becomes  prominent  beneath 
the  skin,  evidently  restricting  the  range  of  motion.  In  most  instances 
the  sternal  division  of  the  muscle  appears  to  be  more  shortened  than 
the  clavicular  portion. 

In  exceptional  cases  the  deformity  even  in  infancy  may  be  extreme, 
and  it  may  be  accompanied  by  well-marked  asymmetry  of  the  face  and 
even  by  distortion  of  the  skull.     In  this  class  the  shortening  may  in- 


476 


CONGENITAL  AND  ACQUIRED   TORTICOLLIS. 


volve  all  the  lateral  tissues,  both  anterior  and  posterior.  Slight  asym- 
metry may  be  present  at  birth,  and  in  the  acquired  form  it  is  usually 
evident  soon  after  the  onset  of  the  deformity,  becoming  more  marked 
with  its  continuance.  Its  cause  is  the  constrained  attitude,  the  restric- 
tion of  normal  use  and  consequently  of  the  blood  supply,  combined 
with  the  tension  upon  the  tissues  of  the  face,  as  is  evidenced  by  the  fact 
that  it  becomes  less  noticeable  after  the  deformity  has  been  corrected. 
In  the  well-marked  cases  of  long  standing,  whether  congenital  or 
acquired,  the  face  is  shorter  and  flatter,  the  nose  and  the  corner  of  the 

Fig.  326. 


Right  torticollis,  showing  the  displacement  of  the  head  toward  the  opposite  side. 

mouth  and  the  eyelids  even  on  the  affected  side  are  drawn  downward 
and  the  skull  shows  evidence  of  atrophy  and  deformity. 

Secondary  distortions  also  appear  in  the  trunk  in  chronic  cases. 
These  are  rotation  of  the  spine  to  compensate  for  the  lateral  distortion 
of  the  head  and  an  increase  in  the  dorsal  kyphosis,  "  round  shoulders." 
Among  the  minor  secondary  deformities  upward  bowing  of  the  clavicle 
caused  by  the  tension  of  the  contracted  muscle  may  be  mentioned. 
(Fig.  325.) 

In  the  early  stage  of  torticollis  the  head  is  tilted  and  is  displaced 
toward  the  contracted  tissues,  but  when  the  deformity  is  of  longer 
standing  the  head  following  the  compensatory  convexity  of  the  cervical 
spine  appears  to  be  displaced  toward  the  opposite  shoulder.     (Fig.  326.) 

The  compensatory  deformities  that  have  been  indicated  are  slight  in 


ETIOLOGY.  4:77 

infancy  but  they  become  more  marked  in  later  childhood,  for  in  many 
instances  the  shortened  muscle  ceases  to  grow  ;  thus  an  original  short- 
ening of  half  an  inch,  as  compared  to  its  fellow  may  be  increased  to 
two  or  more  inches  in  later  years.  This  fact  emphasizes  the  impor- 
tance of  thorough  treatment  as  soon  as  may  be  possible  after  the  distor- 
tion is  discovered. 

As  has  been  stated  the  important  contraction  is  usually  of  the  sterno- 
mastoid  muscle,  but  if  the  deformity  is  uncorrected  all  the  lateral 
tissues  become  shortened,  so  that  at  a  later  stage  complete  division  of 
the  cervical  fascia  as  well  as  of  the  muscles  may  be  necessary  before 
the  deformity  can  be  corrected. 

Typical  wry  neck  caused  by  shortening  of  the  sterno-mastoid  muscle 
is  by  far  the  most  common  form  of  congenital  torticollis,  but  occasionally 
cases  are  seen  in  which  the  head  is  but  slightly  inclined  to  one  side 
and  in  which  the  shortening  appears  to  involve  the  lateral  tissues  in 
general  rather  than  a  particular  muscle.  In  rare  instances,  although 
the  deformity  resembles  that  of  typical  torticollis,  the  greatest  shorten- 
ing will  be  found  to  be  of  the  posterior  muscles  on  one  side,  particularly 
of  the  trapezius  and  the  levator  anguli  scapulje.  Thus  the  scapular 
may  be  elevated  and  tilted  forward.  This  form  of  torticollis  appears 
to  be  one  variety  of  congenital  elevation  of  the  scapula,  (See  page 
185.)  Torticollis  due  to  defective  development  of  the  upper  ex- 
tremity of  the  spine  is  a  rare  deformity  that  does  not  require  special 
description. 

Etiology. — It  may  be  assumed,  disregarding  the  possible  influence 
of  hereditary  predisposition,  that  congenital  torticollis  is,  in  most  in- 
stances, caused  by  a  constrained  or  fixed  position  in  the  uterus  for  a 
longer  or  shorter  time  before  birth.  It  is  in  fact  a  simple  distortion  ; 
and  that  it  has,  in  the  majority  of  cases,  no  deeper  significance  is  proved 
by  the  fact  that  it  may  be  easily  and  completely  cured  by  simple 
division  or  elongation  of  the  contracted  tissues. 

It  would  seem  that  a  deformity  to  be  properly  congenital,  must  be 
present  at  birth,  yet  the  theory,  first  advanced  by  Stromeyer,  that  con- 
genital torticollis  is  the  result  of  injury  at  birth  has  been  so  generally 
accepted  that  it  merits  further  consideration. 

Hsematoma  of  the  Sterno-mastoid  Muscle. — Hsematoma  is  considered 
to  be,  and  undoubtedly  is,  evidence  of  injury.  During  difiicult  deliv- 
ery, fibers  of  the  muscle  are  ruptured,  usually  in  the  upper  or  middle 
third  of  the  anterior  border,  hemorrhage  follows,  which  in  tlirn  is  sur- 
rounded by  an  encapsulating  area  of  inflammatory  material.  This 
forms  a  firm  cylindrical  tumor  in  the  substance  of  the  muscle  which 
becomes  noticeable  two  weeks  after  birth,  or  at  least  this  is  the  time 
when  it  is  usually  discovered  by  the  mother.  As  a  rule,  the  tumor 
is  not  sensitive  to  pressure ;  it  may  or  may  not  be  accompanied  by 
restriction  of  motion  in  the  direction  causing  tension  on  the  muscle. 
The  tumor  remains  for  from  three  to  six  months,  when  it  usually  dis- 
appears, leaving  no  trace  of  its  presence. 

The  theory  of  Stromeyer,  which  until  recently  was  generally  ac- 


478  CONGENITAL  AND  ACQUIRED  TORTICOLLIS. 

cepted,  is  that  congenital  torticollis  is  caused  by  rupture  of  the 
muscle  and  by  myositis  about  the  hsematoma.  This  inflammation  may 
involve  and  ultimately  destroy  a  large  part  of  the  substance  of 
the  muscle  replacing  it  with  fibrous  tissue,  which  contracting,  causes 
deformity. 

This  theory  is  extremely  improbable  for  the  following  reasons  : 

1.  Rupture  of  muscle  elsewhere  is  practically  never  followed  by 
myositis  and  contraction. 

2.  It  has  been  demonstrated  by  Heller/  that  it  is  impossible  to  cause 
myositis  and  contraction  by  any  form  of  injury  to  the  muscles  of 
animals  unless  it  be  combined  with  actual  infection  with  pyogenic 
germs. 

3.  Most  of  the  cases  of  congenital  torticollis  seen  soon  after  birth 
present  no  evidence  of  hsematoma  or  injury,  viz. :  In  7  of  55  cases  of 
supposed  congenital  torticollis  investigated  by  the  writer  there  was  a 
history  of  injury  at  birth.  In  48  cases  no  mention  was  made  of  injury. 
In  the  seven  cases  referred  to  the  deformity  was  accompanied  by 
hsematoma  or  there  was  a  history  of  a  swelling,  apparently  of  this 
nature  ;  but  in  two  of  these  the  hsematoma  was  coincident  wdth  intra- 
uterine shortening  of  the  muscle. 

4.  Cases  of  hsematoma  of  the  sterno-mastoid  muscle  are  not  as  a 
rule  followed  by  torticollis.  Seven  consecutive  cases  of  hsematoma 
were  examined  by  the  writer  with  especial  reference  to  this  point.  In 
all  the  evidence  of  violence  in  delivery  was  clear.  Two  were  delivered 
by  forceps,  three  were  breech  presentations  and  in  two  version  was 
performed.  In  one  case  an  arm  was  broken  and  in  another  paralysis 
resulted  from  injury  to  the  brachial  plexus.  Six  of  the  children  lived 
until  the  swelling  had  nearly  or  entirely  disappeared  and  in  none  did 
torticollis  accompany  or  follow  the  hsematoma. 

5.  In  certain  cases  a  congenitally  shortened  muscle  may  be  ruptured 
at  delivery  ;  thus  the  hsematoma  is  simply  a  complication  of  torticollis, 
not  its  cause.  Bruns  ^  has  reported  such  a  case,  and  two  others  have 
been  observed  by  the  writer,  in  one  of  which  club  foot  was  present 
also. 

6.  Hard  tumors  of  the  sterno-mastoid  muscle  are  not  always  the  re- 
sult of  injury ;  myositis  may  be  of  syphilitic  origin  apparently  occur- 
ring in  intra-uterine  life.  In  other  instances  tumors  of  fibrous  or 
sarcomatous  nature  have  been  removed  from  the  substance  of  the 
muscle. 

Congenital  torticollis  in  the  majority  of  cases  is  of  intra-uterine 
origin.  If  it  follows  injury  at  birth  it  is  probably  an  indirect  result  of 
local  pain,  discomfort  and  irritation  of  the  nerves  or  of  an  actual  in- 
fectious inflammation  of  the  injured  part. 

Pathology. — In  the  ordinary  type  of  congenital  torticollis,  as  demon- 
strated at  operations  on  children,  the  substance  of  the  affected  muscle 
or  muscles  is  simply  lessened  in  amount  and  there  is  a  disproportionate 

'  Heller,  Deutsche  Zeits.  f.  Chir.,  Bd.  49,  H.  2  and  3,  S.  234. 
2  Cent.  f.  Chir.,  No.  26,  1891. 


ETIOLOGY  OF  ACUTE  TORTICOLLIS.  479 

area  of  tendinous  substance  as  compared  to  the  contractile  tissue.  In 
other  instances,  the  muscle  may  be  almost  entirely  replaced  by  fibrous 
tissue,  or  it  may  be  traversed  by  fibrous  bands,  or  patches  of  scar-like 
tissue  may  be  distributed  throughout  its  substance.  These  changes, 
considered  to  be  evidences  of  preexisting  myositis,  are  probably  more 
common  among  the  acquired  than  the  congenital  form  and  as  a  rule 
they  are  found  only  in  cases  of  long  standing.  Secondarily  all  the 
lateral  tissues  of  the  neck  are  shortened  to  correspond  to  the  habitual 
attitude,  and  the  compensatory  curvatures  of  the  spine  in  time  be- 
come fixed,  so  that  torticollis  may  be  classed  as  one  of  the  causes  of 
scoliosis. 

Acquired  Torticollis. 

Acquired  torticollis  is  an  affection  of  early  life,  at  least  80  per  cent, 
of  the  cases  beginning  in  the  first  ten  years. 

As  has  been  stated,  congenital  torticollis  is  usually  a  painless  short- 
ening of  the  muscles,  while  acquired  torticollis  is,  as  a  rule,  a  painful 
affection  secondary  to  injury  or  disease  of  some  of  the  structures  of  the 
neck,  which  causes  peripheral  irritation  of  the  nerves  and  active  con- 
traction of  the  neighboring  muscles.  Thus,  as  a  rule,  the  number  of 
muscles  involved  in  the  deformity  is  greater  than  in  the  congenital 
form  ;  for  example,  in  the  ordinary  form  of  acquired  wry  neck  the 
trapezius,  which  receives  in  part  the  same  nerve  supply,  is  usually 
involved  together  with  the  sterno-mastoid  ;  and  irregular  forms  of  dis- 
tortion caused  by  contraction  of  other  groups,  are  not  uncommon. 

Varieties. — The  varieties  of  acquired  torticollis  may  be  classified 
conveniently  as  follows  : 

1.  The  simple  or  mechanical  form  due  to  scar  contraction  following 
destruction  of  the  skin  or  deeper  tissues,  as  from  burns  or  disease. 

2.  Acute  torticollis  caused  by  direct  inflammation  of  the  muscle,  by 
injury,  by  inflammatory  affections  of  the  surrounding  parts,  combined 
in  most  instances  with  irritation  of  the  peripheral  nerves,  which  causes 
reflex  contraction  of  certain  muscles  or  muscular  groups. 

3.  Spasmodic  Torticollis. — A  form  of  convulsive  spasm,  "  a  disorder 
of  the  cortical  centers  for  rotation  of  the  head."     (Walton.) 

4.  Irregular  forms  of  Torticollis. — Paralytic,  ocular,  psychical  and 
the  like. 

The  first  class,  that  due  to  scar  contraction,  needs  only  to  be  men- 
tioned. 

Etiology  of  Acute  Torticollis. — The  second  class  is  the  most  im- 
portant form  of  torticollis,  both  as  to  frequency  and  as  to  its  effect  in 
causing  permanent  distortion.  Of  this  group,  one  of  the  most  com- 
mon, and  at  the  same  time  the  least  important  form,  is  the  simple 
stiff  neck,  supposed  to  be  due  to  cold  or  to  muscular  rheumatism.  Its 
onset  is,  in  childhood,  sometimes  accompanied  by  slight  fever  and  ma- 
laise ;  the  affected  muscle  is  somewhat  sensitive  to  pressure  and  motion 
or  tension  causes  discomfort.     The  distortion,  in  great  part  voluntary 


480 


CONGENITAL  AND  ACQUIRED   TORTICOLLIS. 


Fig. 


and  accommodative,  is  of  short  duration  as  a  rule.  Strains  and  direct 
injury  of  the  muscles  of  the  neck  may  cause  deformity,  which  usually 
disappears  when  the  local  sensitiveness  has  subsided.  Traumatic 
hsematomata,  similar  to  those  caused  by  injury  at  birth,  are  sometimes 
observed  in  older  subjects.  These  usually  disappear  after  a  time, 
leaving  no  trace  of  their  presence. 

Another  form  of  torticollis  is  secondary  to  cellulitis  and  to  infiltra- 
tion following  the  breaking  down  of  tuberculous  cervical  glands. 
This  may  become  a  permanent  distortion  if  the  deformity  is  allowed 
to  persist  or  if  the  tissues  of  the  neck  are  injured  by  the  suppurative 
process. 

By  far  the  most  important  variety  of  this  class  is  the  acute  spastic 
TORTICOLLIS  due  to  active  tonic  contraction  of  one  or  more  of  the  mus- 
cles of  the  neck.  The  exciting  cause  of  the  spasm  appears  to  be  irri- 
tation of  the  peripheral  nerves  in  the  naso-pharynx  or  in  its  neighbor- 
hood, and  the  muscles  most  often 
affected  are  those  supplied  in  part  by 
the  spinal  accessory  nerve.  Thus  torti- 
collis of  this  form  may  follow  tonsilitis, 
pharyngitis,  measles,  diphtheria  and 
the  like.  It  may  be  preceded  by 
"  toothache  "  or  "  earache,"  or  it  may 
be  an  accompaniment  of  what  appears 
to  be  the  ordinary  form  of  stiff  neck, 
or  of  enlarged  or  suppurating  cervical 
glands.  In  this  form  the  torticollis  is 
caused  directly  by  tonic  contraction  of 
the  muscles.  Reflex  spasm  of  this 
character  is  however  often  associated 
with  the  distortion,  due  primarily  to 
injury  of  the  neck  or  to  some  local  in- 
flammatory process,  so  that  a  sharp 
distinction  between  the  divisions  of 
this  second  class  is  impossible.  Many 
of  the  patients  are  known  to  be  of  a 
nervous  temperament  and  over-study, 
anxiety,  sudden  shock  and  the  like  are 
considered  to  be  predisposing  causes. 

This  variety  of  acquired  torticollis 
completely  overshadows  in  importance 
all  other  forms,  as  is  indicated  by  the  statistics  of  212  cases  treated  at 
the  Hospital  for  Ruptured  and  Crippled  in  which  the  cause  seemed  to 
be  apparent.  Of  the  212  cases  181  may  be  fairly  assigned  to  this 
class. 

The  apparent  exciting  causes  of  cases  of  acquired  torticollis  treated 
at  the  Hospital  for  Ruptured  and  Crippled  is  shown  in  the  following 
table  : 


Bilateral  contraction  of  tlie  sterno- 
inastoids  and  trapezii  muscles.  (See 
Fig.  328. ) 


SYMPTOMS  OF  ACUTE  TORTICOLLIS. 


481 


Enlarged  cervical  glands  14 

Supfturating      "  "     41 

Scarlet  fever 14 

Diphtheria 7 

Mumps 6 

Measles 2 

Sore  throat 8 

Suppurating  otitis  3 

Toothache 6 

Cellulitis  of  the  neck 2 


Furuncle  of  the  neck 1 

Cold  in  the  neck 5 

Rheumatism 18 

Vaccinia 1 

Fever  6 

Malaria 5 

Injury  to  the  neck 35 

Rhachitis 3 

Syphilis 1 

Cicatricial  contiaction 3 

Total T81 


Torticollis  associated  with  chorea 4 

"  "  "      epilepsy 1 

'*  "  "     cortical  irritation 5 

''  ^'  "      hysteria 1 

"  "  "     meningitis 1 

hemiplegia 3 


Spasmodic  torticollis  . . . 
"  Functional  torticollis 


Total 31 


Fig.  P)28. 


Symptoms  of  Acute  Torticollis. — As  a  rule  the  distortion  of  the  neck 
is  slight  at  first,  more  noticeable  at  night  than  in  the  morning ;  it  then 
gradually  increases  until  the 
deformity  becomes  fixed.  In 
other  instances  the  onset  is  sud- 
den, sometimes  accompanied  by 
fever. 

In  most  instances  several 
muscles  are  more  or  less  in- 
volved in  the  contraction,  par- 
ticularly the  sterno-mastoid  and 
the  trapezius,  and  in  such  cases 
the  deformity  is  more  marked 
and  persistent  than  when  the 
sterno-mastoid  is  alone  aiFected. 
Less  often  the  contraction  is 
of  the  posterior  group,  "  pos- 
terior torticollis,"  when  the 
head  is  tilted  backward  and  the 
chin  is  turned  more  toward  the 
opposite  side  than  in  the  typ- 
ical lateral  form.  In  other 
cases  the  contraction  appears  to 
affect  the  small  muscles  that 
control  the  small  joints  at  the  upper  extremity  of  the  spine  when  the 
head  may  be  tilted  forward  with  but  slight  lateral  inclination,  re- 
sembling closely,  except  in  the  history,  the  symptomatic  wry  neck 
of  Pott's  disease.      In  rare  instances  the  muscles  on  both  sides  of 


Bilateral  torticollis  after  treatment.     (See  Fig. 


the  neck  may  be  contracted  simultaneously. 
31 


(Fig.  327.)     The  con- 


482  CONGENITAL  AND  ACQUIRED   TORTICOLLIS. 

tracted  muscles  are  usually  sensitive  to  manipiilatiou  and  attempted 
rectification  of  the  deformity  causes  extreme  pain  and  is  resisted  by  the 
patient.  The  child  is  as  a  rule  nervous  and  irritable,  it  often  com- 
plains of  neuralgic  pain  about  the  contracted  part  which  is  increased 
by  sudden  or  unguarded  movements  or  strain  ;  thus  "  getting  the  patient 
to  bed  "  is  often  a  tedious  proceeding  because  of  the  difficulty  of  sup- 
porting the  head  comfortably  with  the  pillows. 

In  many  instances  the  affection  is  of  short  duration  ;  in  others, 
particularly  those  in  which  the  reflex  spasm  is  aggravated  by  local  in- 
flammatory processes,  there  appears  to  be  but  little  tendency  toward 
recovery.  In  such  cases,  after  several  weeks  or  months,  the  local  pain 
and  sensitiveness  may  subside  together  with  the  active  spasm,  but  the 
deformity  remains,  caused  by  actual  shortening  of  the  muscles  and 
fascia,  aggravated  in  some  instances  by  the  destructive  effect  of  ac- 
tual myositis.  The  muscles  atrophy  and  degenerate  and  present  at  a 
later  stage  the  same  pathological  appearances  that  are  found  in  the 
congenital  form. 

Diagnosis. — Torticollis  is  most  often  confounded  with  Pott's  disease. 
This  w^ould  seem  to  be  hardly  possible  in  cases  of  the  simple  painless 
contraction  of  chronic  torticollis.  In  the  acute  form,  however,  there 
may  be  more  difficulty  in  distinguishing  between  the  two.  The  main 
points  have  been  mentioned  already  in  connection  with  Pott's  disease. 
In  acute  torticollis  the  affection  is  of  sudden  onset,  not  preceded  by  the 
stiffness  and  neuralgic  pain  that  usually  characterize  tuberculous  dis- 
ease. The  deformity  of  torticollis  is  almost  always  of  the  regular  type, 
that  is,  the  head  is  tilted  toward  the  contracted  muscles  while  the  chin 
is  rotated  in  the  opposite  direction.  The  spasm  and  contraction  of  the 
affected  muscles  are  very  plain  and  direct  tension  upon  them  is  painful. 
If  the  contraction  is  relaxed  by  inclining  the  head  toward  the  contrac- 
tion, motion  in  other  directions  will  be  found  to  be  practically  un- 
restricted. 

In  Pott's  disease  the  spasm  of  muscles  is  general,  the  deformity  is 
not  of  a  regular  type,  since  the  chin  often  points  to  the  side  toward 
which  the  head  is  inclined.  Steady  tension  with  the  aim  of  reducing 
the  deformity  is  not  as  a  rule  painful;  in  fact  it  is  often  agreeable  to 
the  patient.  Finally  the  limitation  of  motion  cannot  be  lessened  by 
inclining  the  head  toward  the  muscle  that  seems  to  be  most  contracted, 
for  the  reflex  spasm  of  Pott's  disease  limits  motion  in  every  direction. 
As  a  rule  the  diagnosis  is  easily  made,  but  in  cases  complicated  by  sup- 
puration of  the  cervical  glands  it  is  sometimes  impossible  to  exclude 
Pott's  disease  until  after  the  effect  of  treatment  has  been  observed. 

Disease  of  the  cervical  spine,  other  than  tuberculous,  is  compara- 
tively rare  and  resembles  in  its  symptoms  Pott's  disease  rather  than 
torticollis.  Acute  arthritis  of  the  atlo-axoid  articulation  that  may  be 
a  complication  of  rheumatism  or  that  may  follow  infectious  disease  is 
of  sudden  onset  and  sometimes  resembles  in  the  symptoms  and  de- 
formity the  acute  spastic  torticollis,  except  that  all  the  surrounding 
muscles  are  affected  rather  than  a  particular  group ;  in  fact  but  for 


TREATMENT.  483 

the  history  it  could  not  be  distinguished  from  tuberculous  disease  of 
this  region. 

Although  the  diagnosis  of  torticollis  is  simple,  it  is  not  always  easy 
to  determine  the  muscle  or  muscles  involved  in  the  contraction  of  the 
acquired  form. 

The  effect  of  unilateral  contraction  of  the  different  muscles  is  as 
follows  : 

The  sterno-mastoid  inclines  the  head  toward  the  contraction,  elevates 
the  chin  and  turns  it  in  the  opposite  direction. 

The  trapezius  has  much  the  same  action,  but  the  backward  inclina- 
tion and  rotation  are  more  marked. 

The  action  of  the  complexus  resembles  that  of  the  trapezius,  but  the 
rotation  is  less. 

The  splenius  inclines  the  head  backward  and  toward  the  contracted 
muscle  but  does  not  turn  the  chin  in  the  opposite  direction. 

The  scaleni  have  the  same  action  except  that  the  head  is  inclined 
forward. 

As  has  been  stated,  in  acute  torticollis  several  muscles  are  often  in- 
volved, but  the  spasm  is  usually  greater  in  one  or  in  one  group  than 
in  another.  The  seat  of  greatest  contraction  may  be  determined  by 
the  deformity,  by  the  evident  spasm  that  resists  reposition  and  by  the 
local  sensitiveness  on  palpation.  As  a  rule  when  the  primary  contrac- 
tion is  of  the  posterior  group,  the  deformity  is  more  marked  than  in 
other  forms.  Bilateral  contraction  of  the  muscles  is  rare,  but  it  is  oc- 
casionally seen.     (Fig.  327.) 

Treatment. — The  treatment  varies  according  to  the  cause  and  with 
the  duration  of  deformity.  Excluding,  for  the  present,  the  rare  and  ir- 
regular forms  of  wry  neck  there  are,  from  the  remedial  standpoint,  two 
forms  of  torticollis. 

1.  The  chronic  form — in  which  the  local  pain  and  sensitiveness  are 
absent,  but  in  which  there  is  resistant  and  permanent  deformity.  As 
has  been  stated,  congenital  torticollis  is  included  in  this  class, 

2.  The  acute  form  in  which  the  distortion  is  of  short  duration  and  in 
which  permanent  contraction  may  be  prevented. 

The  Treatment  of  Chronic  Torticollis. — Congenital  torticollis,  if  of 
moderate  degree,  can  be  overcome  in  early  infancy  by  methodical 
stretching  of  the  contracted  parts.  One  person  fixes  the  arm  and  an- 
other draws  the  head  gently  but  firmly  in  the  direction  opposed  to  the 
contraction,  over  and  over  again,  meanwhile  massaging  the  tissues  of 
the  neck.  The  procedure  should  be  repeated  several  times  a  day;  it 
causes  slight  momentary  discomfort  if  properly  performed,  but  this 
ceases  when  the  stretching  is  discontinued.  Care  should  be  taken  also 
that  the  postures  may,  as  far  as  possible,  favor  the  reduction  of  the  de- 
formity; thus  while  the  child  is  in  the  mother's  arms  the  head  should 
be  supported,  and  when  asleep  the  pillow  may  be  arranged  in  a  man- 
ner to  prevent  the  improper  position.  In  this  way  the  torticollis  may 
be  entirely  corrected  or  its  progress  may  be  checked  until  more  effec- 
tive treatment  is  indicated. 


484  CONGENITAL  AND  ACQUIRED   TORTICOLLIS. 

Hsematoma. — The  evidence  of  injury  at  birth  should  be  treated  by 
massage  with  some  bland  ointment ;  if  it  is  accompanied  by  deformity 
the  manipulation  already  described  should  be  employed. 

In  the  great  majority  of  cases  of  congenital  torticollis  the  patient  is 
not  brought  for  treatment  until  the  deformity  has  become  an  eyesore 
to  the  parents.  The  contracted  muscle  is  then  usually  an  inch  shorter 
than  its  fellow,  the  disparity  increasing  as  a  rule  with  the  growth  of 
the  child.  In  such  cases  the  immediate  correction  of  the  deformity  is 
indicated,  and  this  implies  in  most  instances  division  of  the  contracted 
parts  by  subcutaneous  tenotomy  or  by  open  incision. 

If  the  deformity  is  comparatively  slight  and  if  the  contraction  seems 
to  be  limited  to  the  sterno-mastoid,  and  particularly  to  its  sternal  por- 
tion, one  may  hope  to  overcome  the  most  resistant  part  of  the  con- 
traction by  the  subcutaneous  operation.  Aside  from  the  possibility  of 
wound  infection,  which  at  the  present  time  is  an  argument  of  very 
little  weight,  subcutaneous  tenotomy  has  the  advantages  of  simplicity, 
apparent  freedom  from  the  danger  which  parents  associate  with  an 
operation,  and  it  leaves  no  scar  behind.  It  is  totally  inadequate  how- 
ever for  the  correction  of  advanced  cases. 

Correction  of  Deformity  by  Subcutaneous  Tenotomy. — The  patient  and 
the  instruments  having  been  prepared  as  for  an  ordinary  operation,  a 
sand  bag  is  placed  beneath  the  shoulders  and  the  head  is  inclined  so 
that  the  contracted  muscle  is  thrown  into  relief  beneath  the  skin.  The 
sternal  insertion  of  the  tendon  is  seized  with  two  fingers  and  the  teno- 
tome is  inserted  beside  it  and  passed  beneath  it  at  a  point  about  an 
inch  above  the  sternum.  It  is  then  divided  by  a  sawing  motion  of  the 
knife.  Division  of  this  part  of  the  muscle  in  this  situation  is  practi- 
cally free  from  danger  and  in  the  slighter  degrees  of  deformity  one  can 
by  vigorous  manipulation  and  forcible  traction  overcome  the  resistance 
offered  by  the  other  tissues.  If  bands  of  fascia  resist  the  correction, 
they  may  be  divided  by  superficial  nicking  with  the  tenotome  in  the 
lateral  region  of  the  neck.  As  a  rule,  however,  in  cases  of  this  type 
the  open  incision  is  to  be  preferred,  as  it  allows  the  opportunity  for 
free  division  of  the  contracted  parts  with  less  danger  of  injury  to  the 
blood  vessels  and  nerves  in  this  neighborhood. 

The  Open  Operation. — The  incision  should  be  made  in  the  line  of  the 
muscle  midway  between  the  sternal  and  clavicular  insertion.  In  the 
milder  cases  in  childhood,  it  need  be  little  more  than  an  inch  in  length. 
A  director  may  be  passed  beneath  the  tendon  and  on  this  it  may  be 
divided.  The  clavicular  insertion  and  all  bands  of  fascia  that  resist 
the  normal  range  of  motion  may  be  divided  through  the  incision. 

In  cases  of  very  great  deformity  in  the  adult  some  of  the  posterior 
and  as  well  as  the  lateral  muscles  must  be  divided.  In  such  instances 
the  contracted  parts  may  be  divided  at  the  upper  border  of  the  neck 
through  an  incision  from  the  mastoid  process  backward  along  the 
lower  border  of  the  scalp,  the  scar  being  concealed  by  the  hair.  It 
must  be  borne  in  mind  that  the  object  of  the  operation  is,  by  means  of 
division  and  forcible  stretching  of  the  contracted  parts,  to  overcome  all 


THE  OPEN  OPERATION. 


485 


restriction  to  normal  motion,  and  that  the  failure  to  accomplish  this 
usually  explains  the  recurrence  of  deformity,  which  necessitates  the 
use  of  apparatus  after  the  operation. 

Not  only  should  all  resistance  be  overcome  by  vigorous  manipula- 
tion at  the  time  of  operation,  but  the  head  should  be  fixed  during  the 
process  of  repair  in  the  over-corrected  position.  Thus  in  the  treatment 
of  typical  torticollis  the  chin  should  be  turned  to  a  point  over  the 
middle  of  the  clavicle  on 

the  operated  side  and  the  Fig.  329. 

head  should  be  inclined 
toward  the  opposite  shoul- 
der. In  this  attitude  a 
plaster  bandage  should  be 
applied  surrounding  the 
head  and  the  thorax. 
This  bandage  should  re- 
main until  all  local  sen- 
sitiveness has  disappeared 
and  until  the  tendency 
toward  deformity  has  been 
checked.  This  fixation  in 
the  over-corrected  position 
is  very  important  in  child- 
hood, as  an  aid  in  over- 
coming the  deformity 
habit,  but  it  may  be  dis- 
pensed with  in  the  treat- 
mentof  adults.  (Fig.  329.) 

The  plaster  bandage  is 
retained  from  four  to  eight 
weeks  ;  when  it  is  remov- 
ed, massage,  manipula- 
tion and  gymnastic  train- 
ing are  indicated.  Twice 
a  day  the  head  should  be 
forced  to  the  extreme  limit  of  over-correction.  Traction  on  the  neck 
in  self-suspension  by  means  of  the  sling  used  in  the  application  of  the 
plaster  jacket,  a  regular  system  of  exercises  for  the  muscles  of  the 
neck  and  back  and  supervision  of  the  habitual  postures  will  usually 
assure  a  complete  cure.  If,  however,  the  deformity  habit  is  strong 
so  that  the  head  has  a  marked  tendency  to  resume  the  former  attitude 
some  support  is  indicated.  A  simple  and  effective  support  is  the 
jury  mast  as  used  in  the  treatment  of  Pott's  disease  with  the  plaster 
jacket  or  attached  to  a  brace.  In  the  treatment  of  children  a  band  of 
elastic  tape  arranged  to  draw  the  head  toward  the  shoulder  as  sug- 
gested by  Sayre  may  be  sufficient.  In  the  after-treatment  of  the 
advanced  cases,  a  support  modelled  after  that  of  Brown  ^  is  eflPective 
and  comparatively  inconspicuous. 

'  Bradford  and  Lovett,  p.  588. 


Torticollis  left,  showing  the  method  of  fixing  the  head  in 
the  over-corrected  position.    After  operation. 


486  CONGENITAL  AND  ACQUIRED   TORTICOLLIS. 

As  has  been  stated  the  necessity  for  support,  provided  the  deformity 
has  been  thoroughly  over-corrected,  depends  upon  the  care  that  is  to 
be  exercised  in  the  after-treatruent.  When  exercises  and  massage 
can  be  efficiently  employed,  as  a  rule  the  support  will  not  be  required. 
In  other  cases  it  may  be  worn  for  several  months  with  advantage. 

The  principles  of  the  treatment  of  the  chronic  or  painless  form  of 
torticollis  that  have  been  outlined  apply  to  the  acquired,  as  well  as  to 
the  congenital  form,  after  the  subsidence  of  the  acute  symptoms,  when 
passive  shortening  has  replaced  active  contraction.  Acquired  torti- 
collis is,  in  most  instances,  however,  a  preventable  deformity;  thus 
operative  treatment  would  be  rarely  required  had  the  patient  received 
proper  treatment. 

The  Treatment  of  Acute  Torticollis. — The  insignificant  form  of  tor- 
ticollis called  stiff  neck  may  be  treated  by  hot  applications ;  a  firm, 
thick  collar  of  flexible  cotton  stiffened  by  several  layers  of  adhesive 
plaster  is  an  agreeable  support  in  the  more  painful  cases. 

In  true  acute  spastic  torticollis  the  cramp-like  contraction  of  the 
muscles  is  secondary  to  some  irritation  elsewhere,  which  one  should 
always  try  to  remove,  and,  as  has  been  stated,  the  general  condition  of 
the  patient  may  require  treatment  as  well.  But  the  important  indica- 
tion is  to  support  the  head  and  thus  to  relieve  the  pain  and  to  prevent 
permanent  distortion.  In  the  early  stage  the  support  of  the  collar 
that  has  been  described  may  be  sufficient,  but  as  a  rule  patients  of  this 
class  are  not  seen  until  the  distortion  has  persisted  for  weeks  or  months 
even,  so  that  a  more  efficient  form  of  support  is  required — such  is 
the  plaster  jacket  and  jury  mast.  The  elastic  tension  of  this  appliance 
overcomes  the  spasm  and  relieves  the  discomfort  and  apprehension 
which  have  lowered  the  vitality  of  the  patient.  If  the  spasm  is  the 
result  of  the  irritation  of  enlarged  or  suppurating  cervical  glands,  as 
is  often  the  case,  the  rest  afforded  by  the  brace  is  an  effective  treat- 
ment of  the  cause  as  well  as  of  its  effect,  and  if  suppuration  is  present 
this  support  is  most  convenient  for  the  dressing  that  may  be  required. 
When  the  acute  symptoms  and  deformity  have  been  relieved,  manipu- 
lation and  exercises  may  be  employed  in  the  manner  already  described. 

In  cases  of  longer  standing,  particularly  when  the  posterior  muscles 
are  involved,  the  deformity  may  be  forcibly  corrected  under  anaesthesia 
and  the  head  may  then  be  fixed  in  a  plaster  dressing  in  the  manner 
already  described.  This  treatment  may  be  employed  at  an  earlier 
stage  in  selected  cases.  As  a  rule,  when  deformity  has  been  allowed 
to  persist  for  six  months  or  more,  its  rectification  will  require  division 
of  the  more  resistant  tissues. 

Spasmodic  Torticollis. 

Spasmodic  torticollis,  a  form  of  convulsive  spasm  of  the  muscles 
of  the  neck  that  is  somewhat  similar  in  its  general  characteristics  to 
writer's  cramp,^  must  not  be  confounded  with  the  acute  torticollis  of 

1  Spasmodic  torticollis  is  defined  by  Walton  as  a  "  disorder  of  the  cortical  centers  for 
rotation  of  the  head."     Am.  Jour.  Med.  Sci.,  March,  1898. 


TREATMENT.  487 

childhood,  in  which  tonic  spasm  of  the  affected  muscles,  due  usually 
to  some'  well-defined  irritation  of  the  peripheral  nerves,  is  the  charac- 
teristic. Spasmodic  torticollis  is  an  affection  of  adult  life.  Of  32 
cases  collected  by  Richardson  and  Walton,'  but  two  were  in  patients 
less  than  twenty  years  of  age.  The  sexes  are  equally  liable  to  the 
affection  and  the  contraction  is  as  frequent  on  one  side  as  on  the  other. 

The  onset  of  the  affection  is  usually  gradual.  The  first  symptoms 
are  often  sensations  of  stiffness  and  discomfort  in  the  muscles  of  the 
neck;  a  ''  drawing  sensation"  and  a  momentary  twitching  or  slight 
contraction  which  draws  the  head  to  one  side.  These  symptoms  in- 
crease slowly  until  the  head  is  habitually  inclined  in  the  attitude  of 
torticollis.  For  a  time  the  patient  can  correct  the  position  voluntarily, 
or  by  supporting  the  head  with  the  hand  can  restrain  the  twitching  of 
the  muscles,  but  in  well-established  cases  the  head  is  inclined  per- 
manently to  one  side  and  the  convulsive  spasm  is  uncontrollable. 
This  latter  symptom  is  the  most  marked  peculiarity  of  the  affection  ; 
at  intervals  the  head  begins  to  twitch  and  it  is  finally  drawn  by  the 
convulsive  contraction  of  the  muscles  into  an  attitude  of  extreme  de- 
formity. As  the  muscles  most  often  affected  are  the  sterno-mastoid 
and  trapezius  the  attitude  is  usually  one  of  typical  torticollis.  The 
spasmodic  clonic  contractions  may  involve  the  muscles  of  the  face  or 
of  the  chest  even.  They  are  more  marked  when  the  subject  is  excited 
or  when  sudden  movements  are  necessary.  As  a  rule,  patients  com- 
plain of  neuralgic  pain  in  the  head  and  neck,  aggravated  by  the  cramp- 
like contractions. 

Etiology  and  Pathology. — The  etiology  is  obscure.  Many  of  the 
patients  present  a  neurotic  family  or  personal  history,  and  over-work, 
shock  to  the  nervous  system  and  the  like  are  cited  as  predisposing 
causes. 

The  affection  has  been  compared  to  writer's  cramp  as  in  certain  in- 
stances the  spasm  appeared  to  be  caused  by  constrained  positions  of 
the  head  necessitated  by  certain  occupations,  aggravated  it  may  be  by 
the  strain  of  defective  eyesight. 

The  affected  muscles  may  be  hypertrophied  from  constant  activity, 
and  in  the  later  stages  of  the  affection  they  are,  as  a  rule,  permanently 
shortened.  No  characteristic  changes  in  the  nerves  or  in  the  central 
neryous  system  have  been  recorded. 

Prognosis. — There  is  little  tendency  toward  spontaneous  recovery. 
As  a  rule  the  spasm  becomes  more  constant  and  other  muscles  become 
involved. 

Treatment. — It  is  perhaps  unnecessary  to  state  that  the  general 
condition  of  the  patient  and  the  possible  local  and  general  causes  of 
the  spasm  should  receive  consideration.  As  a  rule,  however,  the  pa- 
tient will  have  exhausted  both  constitutional  and  local  treatment  be- 
fore coming  under  observation. 

In  the  mild  and  early  cases  the  avoidance  of  predisposing  causes 
combined  with  massage,  systematic  muscle  training  and  in  exceptional 
^Am.  Jour.  Med.  Sci.,  Jan.,  1895. 


488  CONGENITAL  AND  ACQUIRED   TORTICOLLIS. 

instances  mechanical  support  may  be  of  service,  but  in  the  chronic, 
severe  and  persistent  cases  of  this  class  the  resection  of  nerves  sup- 
plying the  affected  muscles  has  alone  proved  to  be  efficient.  If  the 
spasm  is  limited  to  the  stern o-mastoid  and  trapezius  muscles  resection 
of  the  spinal  accessory  nerve  may  be  sufficient ;  but  if  other  muscles 
are  involved  or  if  the  spasm  recurs  after  the  original  operation,  the  re- 
moval of  the  posterior  branches  of  the  upper  cervical  nerves  together 
with  extensive  division  of  the  contracted  muscles  upon  the  same  side 
and  sometimes  upon  the  opposite  side  also,  may  be  required. 

Resection  of  the  spinal  accessory  nerve  was  first  performed  by  Camp- 
bell de  Morgan,  of  London,  in  1866,  and  since  then  the  operation  has 
been  repeated  many  times  by  other  surgeons  with  temporary  or  perma- 
nent benefit  to  the  patients.  According  to  P6tit  of  26  patients  so  treated 
13  were  cured  and  7  were  permanently  improved.  In  five  others  the 
benefit  was  but  temporary,  one  died  from  erysipelas  following  the 
operation.^ 

The  Operation. — The  spinal  accessory  nerve  passes  downward  and 
backward  from  the  jugular  foramen  and  enters  the  anterior  border  of 
the  sterno-mastoid  muscle  at  a  point  about  one  and  a-half  inches  be- 
low the  tip  of  the  mastoid  process.  At  this  point  it  should  be  exposed. 
Dr.  E.  Eliot,  Jr.,  from  a  special  study  of  the  course  and  relations  of 
the  nerve,  suggests  the  following  method  •? 

"  The  incision  should  be  generous,  for  the  nerve  is  situated  at  a  con- 
siderable depth,  and  should  extend  from  the  mastoid  process  above, 
downward  to  one  or  two  inches  beyond  the  angle  of  the  jaw.  The 
anterior  edge  of  the  sterno-mastoid  should  then  be  exposed.  In  the 
upper  part  of  the  wound,  the  posterior  and  inferior  portion  of  the  pa- 
rotid gland  may  have  to  be  drawn  forward,  although  usually  it  does 
not  overlap  the  muscle.  When  this  is  done,  it  is  comparatively  easy  to 
expose  by  blunt  dissection  tlie  transverse  process  of  the  atlas,  as  it  lies 
directly  below  the  mastoid  process  above,  while  immediately  in  front 
of  this  bony  prominence,  and  running  downward  and  forward  from 
the  mastoid  process  toward  the  angle  of  the  jaw,  is  the  posterior  belly 
of  the  di'gastric.  Behind  this  lie  the  main  vessels  of  the  neck  with  the 
spinal  accessory  nerve  emerging  from  the  jugular  foramen  and  the 
operator  is  certain  that  no  harm  can  be  done  to  these  structures  as 
long  as  he  remains  superficial  to  the  digastric  belly,  which  in  its  turn 
lies  at  a  considerable  depth — in  fact,  at  about  the  level  of  the  trans- 
verse process  of  the  atlas. 

"  Owen  and  Petit  have  drawn  attention  to  the  fact  that  the  nerve 
usually  enters  the  mastoid  muscle  at  a  point  opposite  the  angle  of  the 
jaw.  I  have  found,  however,  in  a  large  majority  of  cases,  that  on 
leaving  the  internal  jugular  it  assumes  a  definite  relationship  with  the 
transverse  process  of  the  atlas.  Never  above  it,  sometimes  directly 
over  it,  usually  a  fraction  of  an  inch  in  front  of  its  most  prominent 
part,  the  nerve  may  easily  be  detected  in  the  small  amount  of  connec- 
tive tissue  that  envelops  it,  and  from  this  point  to  its  entrance  into 
iL' Union  M&licale,  July  9,  1897.  "  Annals  of  Surgery,  May,  1895. 


OPERATIVE  TREATMENT.  489 

the  belly  of  the  muscle  it  may  be  isolated  with  safety,  and  treated  by 
any  suitable  procedure.  If,  exceptionally,  it  should  escape  detection, 
the  anterior  border  of  the  muscle  should  be  drawn  sharply  backward 
at  a  point  opposite  the  angle  of  the  jaw,  the  nerve  in  this  way  put  on 
the  stretch,  and  by  blunt  dissection  in  the  adipose  tissue  that  separates 
the  under  surface  of  the  muscle  from  the  sheath  of  the  vessels,  the 
nerve  may  readily  be  exposed.  Usually  the  nerve  passes  from  under 
the  posterior  belly  of  the  digastric,  at  a  point  Justin  front  of  the  trans- 
verse process  of  the  atlas,  to  a  point  on  the  deep  surface  of  the  muscle 
just  behind  its  anterior  margin  opposite  the  angle  of  the  inferior  max- 
illa. It  is  sometimes  accompanied  by  a  small  artery  and  vein,  the 
latter  easily  visible,  the  former  a  branch  of  the  occipital.  Rarely  the 
nerve  lies  at  a  considerable  distance  from  the  transverse  process  of  the 
atlas  ;  in  one  case  as  much  as  half  an  inch  anteriorly.  Here  the  nerve 
could  be  found  at  its  entrance  into  the  muscle,  the  landmark  of  the 
transverse  process  having  failed  to  localize  its  situation." 

Richardson  suggests  that  if  tlie  nerve  is  not  readily  found,  its  posi- 
tion may  be  ascertained  by  drawing  the  finger  nail  firmly  across  the 
bottom  of  the  wound,  a  sharp  contraction  following  pressure  upon  it. 
The  nerve  having  been  isolated  a  section  of  an  inch  should  be  removed. 
Richardson  advises  in  addition  vigorous  stretching  of  both  extremities. 
After  division  of  the  nerve  the  spasmodic  contraction  relaxes  and  the 
muscles  become  flaccid,  allowing  the  head  to  be  brought  to  the  normal 
position,  or  if  the  deformity  has  become  permanent  the  contracted  parts 
may  be  divided  as  in  the  ordinary  form.  Fixation  of  the  head  is  not, 
as  a  rule,  required.  The  operation  should  be  supplemented  by  massage 
and  by  muscle  training.  If  the  spasm  has  been  confined  to  the  muscles 
supplied  by  the  spinal  accessory  nerve,  the  treatment  may  be  perma- 
nently successful,  but  in  many  instances  the  spasm  may  recur  in  other 
muscles.  Of  these,  the  posterior  group  of  the  opposite  side  is  more 
often  aifected  and  a  similar  operation  for  resection  of  the  posterior 
branches  of  the  upper  cervical  nerves  may  be  indicated.  This  has  been 
performed  with  success  by  Smith  of  London,  Keen,  Richardson  and 
others.  According  to  Smith  ^  the  operation  should  be  conducted  as 
follows  :  an  incision  is  carried  downward  from  the  occiput  about  three 
inches  in  length,  parallel  to  and  one  inch  from  the  spinous  processes. 
It  is  continued  through  the  trapezius  to  the  edge  of  the  splenius. 
The  complexus  is  then  divided  and  the  posterior  branches  of  the  nerves 
are  exposed  ;  those  of  the  three  upper  nerves  which  supply  the  pos- 
terior rotators  are  then  resected. 

Keen  ^  operates  in  a  somewhat  different  manner,  by  a  transverse  in- 
cision two  and  a-half  inches  in  length  from  the  middle  line  of  the 
neck  on  a  level  with  a  point  one-half  an  inch  below  the  level  of  the 
lobule  of  the  ear.  The  trapezius  is  divided  transversely,  afterwards 
the  complexus,  care  being  taken  to  spare  the  great  occipital  nerve. 
The  posterior  branch  of  the  second  cervical  nerve  is  then  resected, 
the  sub-occipital  nerve  is  then  looked  for  in  the  sub-occipital  triangle 
^Spasmodic  Wry  Neck,  London,  1891.         ^^^^als  of  Snrf>-erv,  January,  1891. 


490  CONGENITAL  AND  ACQUIRED   TORTICOLLIS. 

traced  down  to  the  spine  and  divided.  The  external  trnnk  of  the 
posterior  division  of  the  third  occipital  nerve  is  then  exposed  below  the 
great  occipital  and  divided  close  to  the  bifurcation  of  the  nerve  trunk,, 
thus  the  nerve  supply  of  the  chief  posterior  rotators,  the  splenius  capitis,, 
the  rectus  capitis,  posticus  major  and  the  obliquus  inferior  is  removed. 

The  paralysis  that  follows  even  such  extensive  operations  seems  to 
inconvenience  the  patient  but  slightly,  Avhile  the  relief  from  deformity 
and  from  the  constant  spasm  is  a  more  than  sufficient  compensation  for 
whatever  weakness  or  disability  may  result. 

The  following  are  the  conclusions  of  Richardson  and  Walton:^ 

1.  Palliative  treatment,  whether  by  drugs,  apparatus  or  electricity, 
will  rarely  prove  successful  in  well-established  spasmodic  torticollis. 

2.  Massage  may  prove  of  value  in  comparatively  recent  cases. 

3.  Resection  affords  practically  the  only  rational  remedy. 

4.  Operation  on  the  spinal  accessory  nerve  may  afford  relief,  even 
if  other  muscles  than  the  sterno-cleido-mastoid  are  affected ;  on  the 
other  hand  the  affection  previously  limited  to  the  sterno-cleido-mastoid 
may  spread  to  other  muscles  in  spite  of  this  operation. 

5.  No  fear  of  disabling  paralysis  need  deter  us  from  recommending 
operation,  as  the  head  can  be  held  erect  even  after  the  most  extensive 
resection. 

6.  The  most  common  combination  of  spasm  is  that  involving  the 
sterno-mastoid  on  one  side  and  the  posterior  rotators  on  the  other,  the 
head  being  held  in  the  position  of  sterno-mastoid  spasm  with  the  addi- 
tion of  retraction  through  the  greater  power  of  the  posterior  rotators. 

7.  It  seems  advisable  in  most  cases  to  give  preference  to  the  resec- 
tion of  the  spinal  accessory  as  the  preliminary  procedure. 

In  a  later  communication  Richardson  and  Walton  ^  report  very  sat- 
isfactory final  results  on  cases  treated  by  resection  of  nerves  supplying 
the  muscles  that  were  affected  by  the  spasm  on  one  or  both  sides,  com- 
bined with  complete  division  of  the  muscles  as  well,  when  permanent 
contraction  was  present. 

Kalmus^  has  reviewed  the  literature  of  the  subject.  In  eleven  cases 
of  simple  stretching  of  the  spinal  accessory  nerve,  three  were  cured.  In 
sixty-eight  cases  the  nerve  was  resected;  of  these  twenty-three  were 
cured  and  twenty  were  improved.  In  four  there  was  no  improvement 
and  in  one  the  patient  died.  In  fifteen  cases  the  resection  of  the  nerve 
was  supplemented  by  division  of  cervical  nerves ;  ten  of  these  were 
cured  and  three  were  improved.  In  two  others  the  sterno-mastoid 
muscle  was  divided. 

IRREGULAR    AND    EXCEPTIONAL    FORMS    OF    TORTICOLLIS. 

Paralytic  Torticollis. 

One  or  more  of  the  muscles  of  the  neck  may  be  paralyzed  as  from 
anterior  poliomyelitis  and  thus  a  deformity,  due  at  first  to  simple  weak- 

^  Annals  of  Surgery,  January,  1891. 
2  Am.  Jour.  Med.  Sci.,  July,  1896. 

•■' Zur  Operativ  Behand.  Caput.  Obst.  Sjjasticum,  Beitrilge  zur  Klin.  Chir.,  Bd.  26, 
1900. 


PSYCHICAL   TORTICOLLIS.  491 

ness,  and  later  to  the  permanent  effects  of  the  disability  may  be  the 
result,  s 

Diphtheritic  Paralysis  and  Torticollis. 

The  muscles  of  the  neck  may  be  involved  in  paralysis  following 
diphtheria.  In  this  form  the  trapezii  muscles  are  as  a  rule  involved 
so  that  the  head  hangs  forward,  but  occasionally  the  paralysis  may  be 
accompanied  by  contraction  of  one  of  the  sterno-mastoids.  The  his- 
tory, the  evident  weakness,  and  the  paralysis  of  the  soft  palate  or  other 
parts,  which  is  often  present,  usually  make  the  diagnosis  clear. 

Cervical  Opisthotonos. 

In  the  course  of  certain  forms  of  disease  of  the  nervous  system,  for 
example  cerebro-spinal  or  basilar  meningitis,  the  head  may  be  drawn 
backward  by  spasm  of  the  posterior  muscles.  A  slight  degree  of  the 
same  deformity  is  sometimes  seen  in  ill-nourished  infants  not  suffering 
from  serious  disease.  This  and  the  preceding  distortion  are  of  some 
importance  because  they  may  be  mistaken  for  symptoms  of  Pott's  dis- 
ease and  they  have  been  described  in  that  connection.     (See  page  55.) 

Rhachitic  Torticollis. 

During  the  course  of  acute  rhachitis,  particularly  when  the  char- 
acteristic deformity  of  the  lower  part  of  the  spine  is  well  marked,  the 
head  may  be  tilted  backward  usually  as  a  compensatory  attitude,  but 
occasionally  slight  spasm  of  the  posterior  muscles  may  increase  the  dis- 
tortion ;  so  also  when  lateral  deviation  of  the  spine  is  present  due  to 
rhachitis,  the  neck  may  participate  in  the  deformity  as  in  other  forms 
of  rotary  lateral  curvature.  This  is  not  torticollis,  however,  in  the 
proper  sense. 

Ocular  Torticollis. 

Several  cases  have  been  recorded  in  which  the  head  was  habitually 
held  in  a  distorted  attitude  because  of  defective  vision  or  irregularity 
in  the  action  of  the  muscles  of  the  eyes.  This  is,  however,  rather  an 
improper  attitude  than  a  variety  of  true  torticollis.^     (Fig.  143.) 

Psychical  Torticollis. 

A  distortion  of  the  head,  apparently  due  to  the  inability  of  the 
patient  to  control  the  muscles  of  the  neck  has  been  described  by  Bris- 
saud.^  The  deformity  was  not  due  to  muscular  spasm  since  it  could 
be  corrected  by  the  pressure  of  a  finger  on  the  head.  The  condition  is 
called  by  Brissaud  a  local  paralysis  of  the  will,  a  form  of  neurosis 
allied  to  neurasthenia,  epilepsy,  and  functional  spasm. 

1  Hobby,  Med.  News,  June  11,  1898,  p.  772. 

2  These  de  Paris,  1894. 


CHAPTER    XX. 


DISABILITIES  AXD  DEFORMITIES  OF  THE  FOOT. 

General  Description  of  the  Foot  and  of  Its  Functions. 

The  function  of  the  foot  is  two-fold  :  to  serve  as  a  passive  support 
of  the  weight  of  the  body,  and  as  an  activ^e  lever  to  raise  and  propel 
it.  For  the  proper  performance  of  these  functions,  the  foot  is  con- 
structed to  allow  elasticity  under  pressure,  and  an  alternation  of  atti- 
tudes under  strain,  that  protect  it  from  injury. 

The  Arches. — The  most  noticeable  peculiarity  of  the  foot  is  the  ar- 
rangement of  its  arches.     As  has  been  suggested  by  Ellis  and  others, 

Fig.  330. 


Longitudinal  section  of  the  cast  of  the  arch  at  the  point  A  in  Fig.  331  ;  A,  the  astragalo-scaphoid 
junction  ;  B,  the  internal  tuberosity  of  the  os  calcis  ;  C,  the  head  of  the  first  metatarsal  bone. 

the  construction  and  shape  of  the  arched  part  of  the  foot  may  be  better 
understood  by  considering  it  as  half  of  the  arch  formed  by  the  two 
feet.  This  complete  arch  may  be  demonstrated  by  making  an  imprint 
of  the  apposed  feet  in  plaster  of  Paris.  The  plaster  cast  which  repre- 
sents  it  will  appear  in  shape  somewhat  like  an  inverted  saucer,  the 


Fig.  .331. 


Cross  section  of  the  cast  of  the  arches  of  the  apposed  feet.     A.  The  internal  and  inferior  angle  of  the 

astragalo-scaphoid  junction. 

part  of  each  foot  that  rests  upon  the  ground  forming  half  of  an  irregular 
ring.  If  the  plaster  cast  is  sawed  into  equal  sections,  it  will  be  seen 
that  the  highest  or  thickest  part  of  each  division  is  at  the  astragalo- 
scaphoid  junction ;  from  this  point  the  arch  descends  sharply  to  the 


DESCRIPTION  OF  THE  FOOT  AND   OF  ITS  FUNCTIONS.       493 

tuberosities  of  the  os  calcis  and  gradually  to  the  outer  border,  beneath 
the  cuboid  bone,  and  to  the  metatarso-phalangeal  joints.  (Fig.  330.) 
A  cross  section  of  the  cast  will  show  the  contour  of  what  is  sometimes 
called  the  TRANSVERSE  ARCH  (Fig.  331),  while  the  section  through  the 
long  diameter  will  demonstrate  the  shape  of  the  longitudinal,  arch. 
In  descriptions  of  the  longitudinal  arch,  it  is  often  divided  into  two  parts, 

Fig.  332. 


The  bones  of  the  right  foot,  viewed  from  the  outer  side.     (Testut.  )    (From  Gerrish's  Anatomy.) 

of  which  the  outer  division  is  formed  by  the  os  calcis,  the  cuboid,  and 
the  two  outer  metatarsal  bones.  Of  this  outer  arch,  the  highest  point 
is  at  the  calcaneo-cuboid  articulation  (Fig.  332),  and  although  it  is 
normally  a  permanent  arch  yet  the  soft  tissues  are  forced  downward 
beneath  it  when  weight  is  borne,  so  that  the  outer  border  of  the  foot 
makes  an  imprint  throughout  its  entire  length,  as  contrasted  with  the 

Fig.  333. 


The  bones  of  the  right  foot,  viewed  from  the  inner  side.     (Testdt. )     (From  Gerrish's  Anatomy.) 


inner  and  deeper  arch  formed  by  the  os  calcis,  the  astragalus,  the 
scaphoid,  the  cuneiform  and  the  three  inner  metatarsal  bones.  (Fig. 
333.)  This  division,  although  an  artificial  one,  is  of  some  service  in 
calling  attention  to  the  fact  that  the  outer  or  lower  arch  is  more  solidly 
braced  and  therefore  better  adapted  to  continuous  weight-bearing  than 
is  the  higher  and  more  elastic  inner  arch. 


494  DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT. 

The  diagram  of  the  longitudiual  arch,  showing  its  sharp  descent  from 
the  highest  point  to  the  center  of  the  heel,  demonstrates  the  fact  that 
the  heel  is  well  adapted  for  weight-bearing,  while  the  long  anterior 
pillar  composed  of  several  bones  is  less  strong  but  more  elastic ;  thus 
one  instinctively  extends  the  foot  in  descending  stairs,  for  example,  to 
avoid  the  unpleasant  jar  of  direct  shock  received  upon  the  heel.  Of 
this  anterior  pillar,  the  third  metatarsal  bone  is  the  most  direct  sup- 
port, while  the  more  movable  first  and  fifth  metatarsals,  more  under 
muscular  control,  aid  in  balancing  the  weight  upon  the  center  of  the 
foot. 

Both  divisions  of  the  longitudinal  arch  are  permanent  arches,  but 
there  are  two  others  w^hich  are  obliterated  under  weight ;  one  of  these 
is  that  formed  by  the  heads  of  the  metatarsal  bones,  the  anterior 
METATARSAL  ARCH.  In  the  Unweighted  foot,  the  second  and  third 
metatarsal  bones  occupy  a  higher  plane  than  their  fellows,  but  when  the 
erect  posture  is  assumed,  the  anterior  arch  is  depressed  to  allow  all  the 
metatarsal  heads  to  bear  their  share  of  the  weight.  The  other  arch 
does  not  rest  upon  the  ground  but  is  formed  by  the  internal  border  of 
the  foot,  which  curves  slightly  outward,  so  that  when  the  two  feet  are 
placed  side  by  side  an  interval  remains  between  them,  widest  at  the 
highest  point  of  the  longitudinal  arch,  as  is  shown  in  the  diagram  by 
the  upright  section  which  divides  the  cast  of  the  two  soles  from  one 
another,  the  ixterxal  arch.  (Fig.  331.)  When  weight  is  borne, 
this  curved  contour  of  the  foot  becomes  straighter,  or  obliterated  or 
even  transformed  to  an  arch  whose  convexity  is  internal.  (Figs.  351, 
352.) 

The  Foot  as  a  Passive  Support. — The  foot  is  supported  by  the 
muscles,  by  ligaments,  and  by  the  strong  plantar  fascia  that  covers  in 
the  sole.  When  the  foot  is  actively  used,  it  is  in  great  part  supported 
by  the  muscles,  but  when  it  serves  as  a  passive  support,  as  in  standing, 
the  ligaments  bear  the  greater  part  of  the  strain,  and  its  normal  elas- 
ticity allows  the  bearing  surface  to  expand  slightly  as  the  arches  are 
slightly  depressed.  If  this  normal  elasticity  is  diminished,  as  is  some- 
times the  case,  the  supports  of  the  arch  are  subjected  to  abnormal 
pressure  and  the  individual  may  suffer  from  sensitive  corns  or  calloused 
skin  beneath  the  bones.  Or  if  the  ligaments  allow  abnormal  expansion, 
the  arches  may  become  permanently  depressed  and  as  a  result  the  range 
of  motion  necessary  to  the  proj»er  functional  use  of  the  foot,  may  be 
permanently  restricted. 

When  the  statement  is  made  that  the  foot  broadens  and  that  the 
arches  are  slightly  depressed  under  weight,  it  must  not  be  understood 
that  the  longitudinal  arch  is  simply  flattened  by  direct  pressure  and  by 
elongation  of  elastic  ligaments  and  fascia.  Ligaments  and  fascia  are 
not  elastic  in  this  sense  and  they  are  not,  in  the  normal  foot,  over- 
stretched. The  change  in  contour  is  the  effect  of  normal  motion  in 
the  joints  of  the  foot,  by  which  it  is  placed  in  the  most  favorable  atti- 
tude for  weiffht-bearino;  without  muscular  exertion — the  so-called  atti- 
tude  of  rest. 


IMPROPER  POSTURES.  495 

Of  the  changes  of  contour  that  distinguish  the  foot  used  as  a  passive 
support  from  the  one  that  bears  no  weight,  the  most  significant  is  the 
obliteration  of  the  outward  curve  of  its  internal  border.  This  change 
is  due  to  the  fact  that  the  astragalus,  bearing  the  leg,  rotates  inward 
and  downward  on  the  os  calcis  until  it  is  checked  by  the  resistance 
of  the  ligaments  and  by  the  interlocking  of  the  bones.  The  head 
of  the  astragalus  thus  becomes  slightly  prominent,  the  inner  border  of 
the  foot  is  depressed,  and  an  attitude  is  attained  in  which  the  weight  of 
the  body  may  be  supported  with  but  slight  muscular  exertion.  In  this 
attitude  of  rest,  as  Von  Meyer  has  explained,  there  is  general  fixa- 
tion of  joints  of  the  lower  extremity  which  makes  support  pos- 
sible with  the  least  muscular  exertion.  The  pelvis  tilts  slightly  up- 
ward until  tension  is  brought  upon  the  anterior  part  of  the  capsule  of 
the  hip  joint,  the  femur  rotates  slightly  inward,  so  that  the  tibia  is 
turned  outward  in  its  relation  to  it,  and  finally  the  tibia  in  turn  falls 
slightly  inward  upon  the  everted  foot.  To  unlock  the  joints  the  pelvis 
must  be  tilted  forward  or  the  hip  must  be  flexed. 

The  Foot  in  Activity. — The  second  function  of  the  foot  is  as  a 
lever  to  raise  and  to  propel  the  body.  The  calf  muscles  supply  the 
power  and  the  heads  of  the  metatarsal  bones  serve  as  the  fulcrum  on 
which  the  weight  is  to  be  lifted.  When  the  foot  is  used  as  a  lever,  it 
should  be  held  in  such  relation  to  the  leg  that  the  line  of  weight, 
passing  downward  through  the  center  of  the  knee  and  ankle  joints,  is 
continued  over  the  second  toe  or  practically  the  center  of  the  foot.  As 
the  body  is  lifted  over  the  fulcrum  the  forefoot  is  turned  inward  in  its 
relation  to  the  leg  or,  more  properly  speaking,  the  leg  is  turned  out- 
ward because  the  inner  side  of  the  fulcrum,  formed  by  the  first 
metatarsal  bone,  is  longer  than  its  outer  side,  thus  the  strain  is  directed 
toward  the  outer  and  stronger  side  of  the  foot.     (Fig.  334.) 

In  the  proper  walk,  which  is  the  best  illustration  of  the  leverage 
function,  the  feet  should  be  held  practically  parallel  to  one  another,  so 
that  the  line  of  strain  may  fall  through  the  center  of  the  foot.  As 
one  foot  is  advanced  it  first  bears  weight  momentarily  on  the  heel,  then 
upon  its  outer  border ;  the  heel  is  then  raised  and  the  body  is  lifted 
over  the  toes,  the  great  toe  giving  the  final  impulse  to  the  step,  so  that 
if  the  walker  is  looked  at  from  behind,  he  appears  to  be  in-toeing  at 
the  termination  of  each  step.  Thus,  during  the  walk,  there  is  an  al- 
ternation of  postures,  and  the  foot,  under  muscular  control,  assumes 
the  attitudes  most  opposed  to  that  of  passive  support. 

Improper  Postures. — The  alternation  of  postures  and  the  leverage 
action  of  the  foot  are  by  no  means  necessary  to  simple  progression  ; 
for  example,  both  feet  might  be  fixed  in  plaster  bandages  yet  walk- 
ing would  be  possible,  just  as  it  is  possible  on  two  wooden  legs.  In- 
deed, an  approximation  to  such  a  manner  of  walking  is  often  seen,  in 
which  the  feet  are  practically  held  in  the  passive  attitude,  the  weight 
being  borne  upon  the  heels.  Such  a  walk  is  necessarily  jarring  and 
ungraceful,  and  if  it  is  not  the  result  of  weakness  and  deformity  it  pre- 
disposes to  them  because  of  the  disuse  of  the  proper  function  of  the  foot. 


496 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT. 


One  means  of  making  the  leverage  function  difficult  is  the  custom 
of  turning  the  feet  outward.  Outward  rotation  of  the  feet  is  normal 
in  the  passive  attitude  of  weight-bearing,  because  it  enlarges  the  base 
of  support,  locks  the  joints  and  throws  the  strain  upon  the  ligaments 
to  relieve  the  muscles.  On  this  very  account  it  is  the  improper  atti- 
tude for  activity  because  the  strain  falls  upon  the  inner  border  of  the 
foot,  or  to  the  inner  side  of  the  fulcrum,  and  makes  the  proper  exer- 
cise of  muscular  power  and  alternation  of  postures  impossible.  In 
other  words  the  attitude  normal  when  the  foot  is  used  as  a  passive 
support  is  abnormal  when  it  is  in  active  use. 

The  Movements  of  the  Foot. — The  junction  between  the  foot  and 


Fio.  334. 


Fig.  335. 


Illustrates  the  involuntary  adduction  of  the  The  improper  attitude  of  outward  rotation  in  which 
forefoot,  due  to  the  obliquity  of  the  metatarsus,  there  is  disuse  of  the  leverage  function, 

in  the  proper  attitude  for  walking. 

the  leg  is  made  by  means  of  the  astragalus,  a  bone  which  is  not  inti- 
mately connected  with  either  part,  since  it  moves  upon  the  leg  and 
upon  the  foot,  and  to  it  no  muscles  are  attached. 

The  movements  of  the  foot  are  four  in  number :  Dorsal  flexion ; 
plantar  flexion  ;  adduction  ;  abduction. 

Simple  dorsal  and  plantar  flexion  are  confined  to  the  ankle  joint,  but 
complete  plantar  flexion  is  combined  with  slight  adduction,  and  dorsal 
flexion  with  abduction,  because  the  external  facet  of  the  astragalus 
allows  a  greater  range  of  motion  on  the  external  malleolus  than  is  per- 
mitted about  the  internal  malleolus. 

The  range  of  motion  at  the  ankle  joint  is  from  sixty  to  eighty  de- 
grees ;  thus  dorsal  flexion  to  ten  or  twenty  degrees  less  than  the  right 


THE  MOVEMENTS   OF  THE  FOOT. 


497 


angle,  and  plantar  flexion  fifty  to  sixty  degrees  more  than  the  right 
angle.    '(Figs.  336,  337.) 

Adduction  and  abduction  of  the  foot  are  carried  out  in  the  medio- 
tarsal  and  sub-astragaloid  joints. 

Adduction,  the  motion  of  turning  the  foot  inward  in  its  relation  to 
the  leg,  is  always  accompanied  by  inversion  of  the  sole  or  supination, 
because  of  the  shape  of  the  joint  surfaces  between  the  astragalus  and 
OS  calcis,  where  the  greater  part  of  the  motion  takes  place.  Simple 
adduction  and  abduction  without  supination  or  pronation  is  possible  to 
a  very  limited  extent  in  the  medio-tarsal  joint.  Its  range  may  be 
tested  by  fixing  the  heel,  when  the  forefoot  may  be  moved  slightly 
back  and  forth  upon  the  astragalus  and  os  calcis.  The  range  of  mo- 
tion in  the  sub-astragaloid  joint  is  twice  as  free  as  in  the  medio-tarsal 


Fig.  336. 


Fig.  337. 


Voluntary  dorsal  flexion.  Voluntary  plantar  flexion. 

In  these  attitudes  the  astragalus  moves  with  the  foot  upon  the  leg  bones,  as  contrasted  with  adduction 

and  abduction  in  which  the  center  of  motion  is  below  the  astragalus. 


joint.  The  character  of  the  motion  between  the  astragalus  and  os 
calcis  is  rotation  on  an  axis  passing  through  the  upper  and  inner  part 
of  the  head  of  the  astragalus,  downward  and  outward  to  the  outer 
tuberosity  of  the  os  calcis.  Thus  for  all  practical  purposes,  adduction, 
inversion  and  supination  are  synonymous  terms :  the  same  is  true  of 
abduction,  pronation  and  eversion.  Outward  rotation  is,  however, 
quite  distinct,  since  the  center  of  motion  is  at  the  hip  joint. 

In  the  movement  of  adduction  of  the  foot,  the  astragalus  is  fixed 
between  the  malleoli,  and  upon  it  the  os  calcis  glides  forward  and  its 
anterior  extremity  turns  slightly  inward  ;  the  sustentaculum  tali  moves 
backward,  its  inner  superior  surface  is  elevated  and  its  external  sur- 
face is  depressed.  Meanwhile  the  forefoot,  following  the  motion  of 
32 


498 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT. 


the  OS  calcis,  is  carried  inward  about  the  head  of  the  astragalus ;  its 
inner  border  is  elevated  and  its  outer  border  is  depressed,  so  that  the 
sole  looks  inward  and  downward.     In  this  attitude  all  the  arches  are 
ncreased  in  depth.     (Fig.  338.) 

In  abduction  the  bones  move  upon  one  another  in  the  reverse  direc- 
tion, the  curves  are  lessened  and  that  of  the  inner  border  is  obliterated. 
(Fig.  339.) 

The  extreme  of  adduction  is  only  possible  in  the  position  of  plantar 
flexion,  because  in  this  position  the  adduction  possible  at  the  ankle 
joint,  in  part  due  to  the  contour  of  the  astragalus  and  in  part  to  the 

Fig.  339. 


Fig.  338. 


Voluntary  adduction.  Voluntary  abduction. 

In  these  postures  the  foot  moves  upon  the  astragalus  which  is  practically  fixed  between  the  mal- 
leoli. Adduction,  the  turning  of  the  foot  inward  in  its  relation  to  the  leg,  is  al  way?:  accompanied  by  ele- 
vation of  its  inner  and  depression  of  its  outer  border,  This  is  known  as  supination  or  inversion  of 
the  foot.  The  reverse  of  this  attitude — pronation  or  eversion — is  an  accompaniment  of  abduction  as  is 
illustrated  in  the  figures. 

greater  mobility  allowed  in  the  joint  when  the  narrow  posterior  border 
of  the  astragalus  is  alone  in  contact  with  the  malleoli,  is  added  to  the 
adduction  which  the  joints  of  the  foot  permit. 

Extreme  abduction  is  attained  in  the  attitude  of  dorsi-flexion,  its  ex- 
tent being  about  one-half  that  of  adduction  ;  the  entire  range  of  motion 
between  the  two  extremes  being  about  forty-five  degrees. 

In  this  description  the  foot  is  considered  as  moving  on  the  leg, 
but  in  the  attitude  of  rest  the  foot  becomes  the  fixed  point  and  the 
astragalus  moves  upon  the  os  calcis  in  the  manner  and  to  the  position 


THE  MOVEMENTS  OF  THE  FOOT. 


499 


already  mentioned  in  the  description  of  abduction,  i.  e.,  it  slips  down- 
ward arid  forward  and  turns  inward,  and  at  the  same  time  the  anterior 
extremity  of  the  os  calcis  turns  slightly  inward  and  downward,  and 


Fig 


Fig.  341. 


The  direct  dorsal  flexors. 

Tibialis  anterior  of  right  side  :  outline  and  Peroneus  tertius  of  right  side  :  outline  and 

attachment-areas.     (Gerrish.)  attachment-areas.     (Geerish.) 

its  inner  border  is  depressed.  Corresponding  to  this  movement,  as  the 
inner  border  of  the  foot  becomes  straight  or  bulges  inward,  the  scaphoid 
is  forced  forward  and  downward  and  the  longitudinal  arch  is  depressed. 


500  DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT. 

Fig.  342.  Fig.  343. 


/I 
/ 


The  calf  muscle.    The  plantar  flexor.  ,    *.    , 

Gastrocnemius  of  right  side  :  outline  and  Soleus  of  right  side :  outline  and  attach- 

attachment-areas.     (Gbkrish.)  meut-areas.     (Geerish.) 


THE  MOVEMENTS   OF  THE  FOOT. 


501 


As  has  been  mentioned  the  turning  of  the  leg  inward  and  the  corre- 
sponding turning  of  the  foot  outward  in  its  relation  to  it,  locks  in  a 
manner  the  ankle  joint  and  at  the  same  time  throws  the   strain  upon 


Fig.  344. 


Fig.  345. 


Peroneus   longus  of  right   side :   outline 
and  attachment-areas.     (Gereish.) 


The  direct  abductors. 


Peroneus  brevis  of  right  side :    outline 
and  attachment-areas.     (Gekkish.  ) 


the  ligaments,  so  that  standing  in  the  erect  posture  is  possible  with  but 
little  muscular  exertion.     (Fig.  351.) 

To  put  it  in  a  simpler  manner,  the  leg  supporting  the  weight  of  the 


502 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT. 


Fig.  346. 


N- 


The  most  important  adductor. 

Tibialis  posterior  of  right  side  : 
outline  and  attachment-areas.    The 
most  of  the  muscle  is  represented  as  if 
seen  through  the  bones.    (Geekish.  ) 


body  has  a  tendency  to  tilt  the  foot  over 
toward  the  inner  side  and  to  evert  the 
sole ;  thus,  under  increasing  superincum- 
bent weight,  the  point  of  greatest  pressure 
on  the  sole  shifts  from  its  center  and  outer 
border  toward  the  inner  border.  If  on  the 
other  hand  the  body  is  raised  upon  the 
toes,  the  arch  is  relieved  from  strain  and 
the  weight  falls  upon  the  front  and  outer 
part  of  the  foot.  Plantar  flexion  and  ad- 
duction represent,  as  contrasted  with  the 
passive  attitude  of  supporting  weight,  the 
attitude  of  activity  in  which  the  foot  is 
supported  and  controlled  by  the  muscles. 

The  Function  of  the  Muscles. — The 
most  important  function  of  the  dorsal 
flexors  is  to  lift  the  foot  as  it  is  swung 
forward,  while  the  plantar  flexors  serve  in 
the  active  propulsion  of  the  body.  The 
difi'erence  in  function  is  shown  by  the  rela- 
tive strength  of  the  two  groups,  the  plantar 
flexors  being  five  times  the  stronger;  in  fact, 
the  calf  muscle  (gastrocnemius  and  soleus) 
alone  is  three  times  as  strong  as  all  the  other 
muscles  of  the  foot  combined.  It  is  prac- 
tically the  leverage  muscle,  the  others  serv- 
ing more  especially  to  fix  and  to  hold  the 
forefoot,  or  fulcrum,  in  its  proper  relation 
to  the  leg.     (Figs.  342,  343.) 

The  muscles  that  most  directly  sup- 
port the  inner  arch  of  the  foot  are  the 
tibialis  posticus  and  anticus,  whose  ten- 
dons meet  in  their  insertion  in  front  of 
the  astragalus  in  the  form  of  a  V.  The 
tibialis  anticus  supports  the  internal  bor- 
der of  the  foot  from  above,  and  the  posti- 
cus is  the  most  powerful  adductor.  (Figs. 
340,  346.) 

The  flexor  longus  pollicis,  passing  direct- 
ly beneath  the  sustentaculum  tali,  aids  in 
supporting  the  weak  part  of  the  foot  and 
its  position  demonstrates  the  importance  of 
the  proper  functional  use  of  the  great  toe. 
(Fig.  350.) 

The  peroneus  longus  and  brevis  sup- 
port the  outer  arch  and  the  former  binds 
the  foot  together  and  holds  the  great  toe 
firmly  against  the  ground,  thus  it  indi- 
rectly supports  the  longitudinal  arch 
against  direct  pressure.     (Figs.  344,  345.) 


THE  FUNCTION  OF  THE  MUSCLES.  503 

The  relative  strength  of  the  muscles  and  their  functions  is  shown 
in  the  following  tables :  ^ 

Dorsal  Flexors  of  the  Foot  :  Strength  reckoned  in  kilogrammetebs. 

Tibialis  Anticus 0.871 

Extensor  Longus  Digitorum 0.280 

Extensor  Longus  Pollicis 0. 155 

Peroneus  Tertius 0.087 

1.393 
Plantar  Flexors. 


The  calf  muscle 


Soleus ....3.256 

Gastrocnemius 2.831 

Flexor  Longus  Pollicis 0.218 

Peroneus  Longus 0. 118 

Tibialis  Posticus 0.094 

Flexor  Longus  Digitorum 0.078 

Peroneus  Brevis 0. 055 

6.650 

Relative  Strength  of  the  Supinators  of  the  Sub-Astragaloid  Joint. 

strength.  Weight  of  the  Muscles. 

Soleus 1.021 

Gastrocnemius 0.709 

Tibialis  Posticus 0.337 

Flexor  Longus  Pollicis 0.172 

Flexor  Longus  Digitorum 0.123 

2.362 

Relative  Strength  of  the  Pronators  of  thk  Sub-Astragaloid  Joint. 

strength. 

Peroneus  Longus 0. 282 

Peroneus  Brevis 0. 192 

Extensor  Longus  Digitorum... 0.164 

Peroneus  Tertius 0.067 

Extensor  Longus  Pollicis 0.045 

Tibialis  Anticus 0.021 

0.771  123.7 

Relative  Strength  of  the  Supinators  of  the  Medio-Tarsal  Joint. 

Tibialis  Anticus 0.238 

Tibialis  Posticus 0.078 

Flexor  Longus  Pollicis 0. 034 

Flexor  Longus  Digitorum 0. 033 

Extensor  Longus  Pollicis 0. 030 

0.413 

Relative  Strength  of  the   Pronators  of  the  Medio-Tarsal  Joint. 

Peroneus  Longus 0. 162 

Peroneus  Brevis 0.090 

Extensor  Longus  Digitoi'um 0. 085 

Peroneus  Tertius 0. 033 

0  370 

It  will  be  noticed  that  the  strength  of  the  pronators  and  supinators 

1  Uber  die  Arbeitsleistung  der  auf  die  Fussgelenke  Wirkenden  Muskeln,  E.  Fick 
Leipsic,  1892. 


157.0  Grammes. 

120.0 

39.6 

33.2 

12.3 

362.1 

SUB-ASTRAGALOI] 

Weight  of  the  Muscles, 

24.0  Grammes. 

16.5 

18.2 

3.5 

12.3 

49.2 

504 


DISABILITIES  AND  DEFOBMITIES    OF  THE  FOOT. 


(abductors  and  adductors)  of  the  medio-tarsal  joint  is  nearly  equal, 
and  that  the  great  preponderance  of  power  of  the  supinators  of  the 
sub-astragaloid  joint  is  owing  to  the  fact  that  the  calf  muscle  is  a 


Fig.  347. 


Fig.  348. 


Extensor  proprius  hallucis  of  right  side  :  out- 
line and  attachment-areas.  (Geerish.) 


Extensor  longus  digitoruni  of  right  side  :  out- 
line and  attachment-areas.     (GErrish.) 


supinator.  When  the  foot  is  at  a  right  angle  with  the  leg,  the  power 
of  the  calf  muscle  not  being  utilized,  the  pronators  are  stronger  than 
the  supinators.     It  will  be  noticed  also,  that  the  tibialis  anticus  muscle. 


THE  FUNCTION  OF  THE  MUSCLES. 
Fig.  349.  Fig.  350. 


505 


Flexor  longus  digitorum  of  right  side  : 
outline  and  attachment-areas.  The  muscle 
is  represented  as  seen  from  in  front 
through  the  bones.     (Gerrish.) 


Flexor  lougus  hallucis  of  right  side  : 
outline  and  attachment-areas.  The  mus- 
cle is  represented  as  seen  from  the  front 
through  the  bones.     (Gerrish.) 


506 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOl. 


which  supinates  the  medio-tarsal  joint,  is  reckoned  among  the  pronators 
of  the  sub-astragaloid  joint. 

The  Foot  Considered  as  a  Mechanism. — In  the  study  of  the  de- 
formities, and  particularly  of  the  functional  weaknesses  of  the  foot, 
one  must  never  lose  sight  of  the  fact  that  it  is  a  machine,  subject  to 
the  same  mechanical  laws  that  govern  other  machines,  and  that  its 
deformities  and  disabilities,  its  relati\"e  strength  or  weakness,  may  be 
appreciated  by  comparing  it  with  the  normal  standard.  As  in  other 
machines,  marked  deformity  or  distortion  is  evident  at  a  glance,  even 


Fig.  351. 


Fig.  352. 


An  attitude  that  simulates  flat  foot. 
(See  Fig.  353.) 


Fig.  352,  compared  with  Fig.  351,  will 
illustrate  the  Toluntary  protection  of  the 
foot  from  over-strain. 


though  the  apparatus  is  not  in  use,  but  functional  ability  can  be  judged 
only  by  the  manner  in  which  active  work  is  performed. 

As  has  been  stated,  the  foot  is,  in  activity,  a  lever,  by  means  of 
which  the  weight  of  the  body  is  lifted  and  propelled.  If  it  is  loosely 
constructed  or  insufficiently  supported  by  the  ligaments,  it  is  evident 
that  it  can  not  be  properly  controlled  by  the  muscles.  If,  on  the  other 
hand,  the  muscular  power  is  insufficient,  it  is  evident  also  that  the 
weight  of  the  body  can  not  be  lifted  and  properly  balanced  upon  it. 
The  structure  of  the  foot  may  be  normal  and  its  muscles  may  be  of 
normal  strength  yet  the  strain  placed  upon  it  may  be  disproportionately 


THE   WEAK  FOOT. 


507 


Fjg.  353. 


great.  This  strain  may  be  actual  over-weight,  or  the  over-work  of  a 
laborious  occupation,  but  more  often  the  machine  is  over- worked  simply 
because  it  is  subjected  to  mechanical  disadvantages  in  the  performance 
of  its  functions,  by  the  assumption  of  improper  attitudes. 

An  improper  attitude  is  one  that  limits  or  lessens  the  range  of  mo- 
tion, and  the  alternation  of  postures,  that  protect  the  foot  from 
over-strain.  One  of  the  most  common  of  such  attitudes  is,  as  has  been 
mentioned,  that  of  turning  the  feet  outward  in  walking,  thus  the  ful- 
crum being  displaced  outward,  the  strain  falls  through  the  inner  and 
weaker  side  of  the  foot.  As  a  consequence  of  the  improper  attitude 
there  is  usually,  to  a  greater  or  less 
degree,  disuse  of  the  active  leverage 
function  of  the  foot ;  the  active  lift 
of  the  calf  muscle  is  replaced  by 
exaggerated  flexion  at  the  knee,  the 
foot  being  used  somewhat  as  if  it 
were  a  movable  pedestal.  (Fig. 
335.) 

This  disuse  of  active  attitudes 
may  be  unnecessary,  just  as  the  out- 
ward rotation  of  the  feet  with  which 
it  is  associated  is  a  habit,  a  habit 
that  is  often  the  result  of  improper 
teaching.  On  the  other  hand,  the 
habitual  assumption  of  the  passive 
attitude  may  be  induced  by  injury 
or  disease  of  the  foot,  or  by  corns 
or  bunions,  or  by  improper  shoes. 

Under  such  conditions  the  strain  of  the  leverage  function  increases 
the  discomfort,  consequently  it  is  discontinued.  It  must  not  be 
inferred  that  such  improper  attitudes  lead  directly  to  weakness  and 
discomfort,  for  in  most  instances,  an  ungraceful  carriage  and  gait  are 
the  only  ill  effects.  The  improper  attitudes  must,  however,  lessen  the 
power  and  resistance  of  the  foot  and  they  must  be  reckoned,  therefore, 
among  the  predisposing  causes  of  disability  and  deformity. 

The  passive  attitude,  it  will  be  remembered,  is  the  attitude  of  rest, 
in  which  the  ligaments  bear  the  greater  part  of  the  strain  and  in  which 
the  arches  of  the  foot  are  depressed  or  obliterated. 


Typical  "  flat  foot  "  uf  moderate  degree,  il- 
lustrating the  componeut,  elements  of  abduc- 
tion and  depression  of  the  arch. 


The  Weak  Foot. 

Synonyms. — Splay  Foot,  Flat  Foot. 

This  introduction  leads  naturally  to  the  consideration  of  the  most 
important  of  the  acquired  disabilities  of  the  foot,  a  disability  whose 
most  important  characteristic  in  the  mildest  and  in  the  most  advanced 
type  is  the  persistence  of  the  passive  attitude,  or  an  approximation  to 
it,  in  place  of  active  motion  and  alternation  of  posture.  Disuse 
of  function  is  followed  by  restriction  of  motion,  particularly  in  the 


508 


DISABILITIES  AND   DEFORMITIES   OF  THE  FOOT. 


Fig.  354. 


Fig.  355. 


rauge  of  adduction  and  plantar  flexion,  and  finally  by  persistent  de- 
formity, a  deformity  which  is  simply  an  exaggeration  of  the  normal 
posture  assumed  when  the  foot  supports  weight.  (Fig.  351.)  This  is 
the  so-called  flat  foot.  (Fig.  353.)  At  first  glance^  it  may  seem 
that  the  depression  of  the  arch  is  the  most  noticeable  peculiarity  in  a 
w^ell-marked  case  of  flat  foot,  and  that  the  popular  name  is  therefore 
an  appropriate  term,  but  on  closer  examination  it  will  be  evident  that 
the  normal  relation  between  the  leg  and  the  foot  is  changed.  This 
change,  which  from  the  functional  standpoint  is  of  far  greater  impor- 
tance than  the  depth  of  the  arch  may  be  analyzed  as  follows  : 

The  Anatomy  of  the  Weak  Foot. — 1.  The  leg  is  displaced  inward 
so  that  the  weight  falls  upon  the  inner  side  of  the  foot ;  2.  The  leg  is 
rotated  inward,  so  that  a  line  drawn  through  its  center,  prolonged 
from  the  crest  of  the  tibia,  instead  of  falling  over  the  second  toe  now 
points  inside  the  great  toe,  or  even  over  the  center  of  the  internal  bor- 
der of  the  foot.     (Figs.  353-356.) 

It  has  been  stated  that  under  normal  conditions  in  the  act  of  passive 
weight-bearing,  the  astragalus  rotates  downward  and  inward  upon  the 
OS  calcis,  depressing  its  anterior  and  internal  border  until  the  move- 
ment is  checked  by  the  strong  ligaments  connecting  the  bones,  the  cal- 

caneo-scaphoid,  the  deltoid 
and  the  interosseus  ;  in  other 
words  the  leg  has  a  tendency 
to  slip  downward  and  inward 
from  off  the  foot.  In  the 
weak  foot  this  inclination 
has  become  an  accomplished 
fact,  for  the  normal  movement 
has  become  so  exaggerated  by 
the  distention  of  the  ligaments 
and  by  the  weakness  of  the 
supporting  muscles  that  an 
actual  partial  dislocation  has 
taken  place.  The  astragalus  has  rotated  and  slipped  far  to  the  inner 
side  of  its  normal  position  and  to  an  attitude  of  exaggerated  rotation 
and  moderate  plantar  flexion,  so  that  its  head  can  be  plainly  felt  on 
the  internal  border  of  the  foot.  The  os  calcis  has  been  forced  into  an 
attitude  of  pronation.  Its  anterior  extremity  is  depressed  and  turned 
slightly  inward  and  its  internal  border  is  lowered.      (Fig.  355.) 

The  scaphoid  bone  has  been  depressed  with  the  head  of  the  astraga- 
lus, although  to  a  less  degree,  and  has  been  forced  further  away  from 
the  OS  calcis,  and  with  it  the  entire  inner  border  of  the  foot  is  depressed 
also.  Thus  the  depression  of  the  arch  is  ahvays  accompanied  by  a 
bulffinp;  inward  of  the  inner  side  of  the  foot. 

The  typical  flat  foot  is,  as  it  were,  broken  in  the  center  (Fig.  366), 
the  posterior  division  having  turned  inward  and  downward  ;  that  is, 
the  astragalus  has  rotated  inward  and  downward  to  an  extreme  degree 
and  has    slipped  from  off  the  os  calcis.     The  latter  bone,  although 


The  relatiou  of  the 
astragalus  to  the  os  cal- 
cis. 


The  relation  of  the 
astragalus  and  os  calcis 
in  flat  foot. 


IHE   WEAK  FOOT. 


509 


Fig.  356. 


forced  outward  in  its  relation  to  the  astragalus,  still  turns  inward 
slightly,  while  the  forefoot  in  its  relation  to  the  leg  is  greatly  abducted. 
The  dislocation  may  be  so  extreme  that  the  entire  sole  of  the  foot  rests 
upon  the  ground,  and  a  callus  even  may  be  found  at  the  point  that 
usually  represents  the  highest  point  of  the  arch,  which  now  supports 
the  greatest  burden. 

In  this  change  of  relation  between  the  bones  the  arched  part  of  the 
foot,  or  waist,  appears  much  broader  than  normal,  even  broader  than 
the  front  of  the  foot ;  the  heel  projects,  the  external  malleolus  is  de- 
pressed and  carried  forward  by  the 
rotation  of  the  leg  and  is  much  less 
prominent  than  normal ;  the  internal 
malleolus  is  more  prominent  and  with 
the  astragalus  it  overhangs  the  bearing 
surface  of  the  sole.  The  entire  ma- 
chine is  twisted  and  out  of  gear,  its 
motion  is  therefore  very  much  re- 
stricted. It  is  manifestly  impossible 
for  the  patient  to  adduct  the  forefoot, 
that  is  to  turn  it  inward  about  the 
head  of  the  displaced  astragalus. 
Plantar  flexion  is  also  much  limited, 
because  of  the  permanent  position  of 
adduction  and  plantar  flexion  that  the 
astragalus  has  assumed.  Dorsal  flex- 
ion, on  the  other  hand,  although  it  is 
actually  restricted,  may  appear  to  be 
abnormally  free,  because  the  forefoot  is 
abducted  and  slightly  dorsi-flexed  upon 
the  head  of  the  astragalus.     (Fig.  353.) 

The  disability  and  its  accompanying 
deformity,  is  found  in  every  grade  of 
severity.  Pain  begins  when,  the  sup- 
port of  the  muscles  being  insufficient, 
the  ligaments  begin  to  give  way  under 
strain,  allowing  the  bones  to  occupy  an 
abnormal  relation  to  one  another.  It  is 
evident,  therefore,  that  the  individual 
in  whose  foot  the  arch  is  well  formed 
and  whose  ligaments  are  firm,  will  suffer  from  the  symptoms  of  strain 
long  before  the  arch  has  been  depressed  or  deformity  has  become  appa- 
rent; also  that  the  lateral  inward  bulging,  characteristic  of  advancing  de- 
formity, must  be  very  great  before  the  arch  is  completely  flattened.  In 
this  type  the  prominent  deformity  is  lateral  displacement  (valgus).  On 
the  other  hand,  if  the  individual  has  inherited  a  low  arch,  as  is  charac- 
teristic of  certain  races,  or  if,  as  the  result  of  weakness  in  early  life,  the 
arch  has  been  depressed  or  has  never  formed,  accommodative  changes 
in  the  bones  will  have  taken  place  during  growth,  so  that  the  flat  foot 


Weak  feet,  showing  the  inward  rota- 
tion of  the  legs  when  the  abducted  feet 
are  placed  side  by  side. 


510 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT. 


Fig.  357. 


of  this  type  will  not  be  attended  with  as  much  change  in  its  relation  to 
the  leg,  and  therefore,  disturbance  of  function,  as  in  the  typical  case 
that  has  been  described.  This  latter  class  of  cases  exemplifies  the 
popular  type  of  flat  foot  that  may  exist  without  pain  or  disability  and 
in  which  the  most  noticeable  peculiarity  is  the  obliteration  of  the  arch 
(planus).     (Contrast  Figs.  357  and  358.) 

In  certain  instances,  abnormal  laxity  of  ligaments  allows  deformity 
of  the  valgus  type  when  weight  is  borne,  yet  the  foot,  controlled  by 
efficient  muscles,  may  be  apparently  normal  in  functional  ability,  while 
in  other  cases  in  which  the  ligaments  are  resistant  and  yet  are  sub- 
jected by  insufficient  muscular  protection  to  over-strain,  disability  and 

pain  may  precede  noticeable  deformity. 
It  is  very  evident  that  the  lowering 
of  the  arch  is  of  secondary  importance 
in  the  deformity  and  that  the  popular 
significance  of  painful  flat  foot,  as  an 
inherited  and  irremediable  weakness, 
is  most  misleading.  Yet  it  seems  to 
have  governed  the  treatment  of  the  dis- 
ability until  very  recently.  On  the  one 
hand,  the  early  cases  were  overlooked 
because  the  foot  was  not  flat,  while 
those  in  which  the  deformity  was  more 
advanced  were  simply  neglected  or 
were  treated  by  simple  supports  be- 
neath the  arch  or  by  operation,  with- 
out regard  to  the  loss  of  function,  and 
therefore  without  hope  of  ultimate  cure. 
As  has  been  stated,  there  is  one 
feature  common  to  every  grade  of 
the  so-called  flat  foot ;  the  foot 
regarded  as  a  machine  is  weak,  as 
compared  to  the  normal  standard — 
weak  because  of  the  persistence  of 
the  attitude  of  rest  and  relaxation,  as  contrasted  wdth  that  of  activity 
and  strength,  and  weak  because  the  proper  relation  between  the  power 
and  the  fulcrum  is  changed.  Even  the  inherited  flat  foot  or  the  flat 
foot  which  has  never  caused  symptoms,  is  weak  in  the  sense  that,  in 
use,  it  lacks  the  spring  and  elasticity  characteristic  of  the  perfect  machine. 
The  term  weak  foot  may  be  used,  then ,  to  indicate  all  types  of  the  dis- 
ability. In  one  weak  foot  the  arch  has  disappeared  (Fig.  358) ;  in 
another  weak  foot  the  arch  is  of  normal  depth  but  the  foot  is  abducted 
or  pronated  in  its  relation  to  the  leg.  (Fig.  357.)  In  one  case  the 
deformity  appears  only  under  weight ;  in  another  the  foot  is  held  rigidly 
in  the  deformed  position  by  muscular  spasm.  In  one  instance  there 
may  be  great  deformity  without  pain  ;  and  in  another,  disabling  weak- 
ness and  pain  without  deformity.  In  one  case  the  foot  is  unable  to 
perform  its  functions    because  of  its  inherent  weakness,  in    another 


Weak  feet,  arch  not  depressed. 


ETIOLOGY.  511 

the  disability  may  be  due  simply  to  the  improper  use  of  a  normal 
structure. 

Pathology. — Supposing  the  foot  to  have  been  normal  before  it  began 
to  break  down,  it  is  evident  that  such  deformity  could  not  have  been 
acquired  without  marked  changes  in  its  internal  structure,  and  that  its 
progress  must  have  been  attended  with  symptoms  of  discomfort  and 
pain.  In  a  general  way,  these  changes  are  such  as  have  been  indicated 
by  the  description  ;  the  ligaments  on  the  internal  aspect  of  the  foot  and 
of  the  ankle  joint  are  weak  and  distended ;  the  unused  portions  of  the 
articular  surfaces  of  the  joints  may  be  denuded  of  cartilage,  while  new 
facets  may  have  formed  to  accommodate  the  changed  relations  of  the 
bones.  For  example,  the  external  malleolus  may  be  in  direct  contact 
with  the  OS  calcis ;  evidences  of  injury  and  of  abnormal  pressure  may 
be  found  in  the  thickened  periosteum,  in  formation  of  osteophytes, 
while  the  internal  structure  of  the  bones  has  been  changed  as  well,  to 
adapt  itself  to  the  new  conditions.  The  muscles  which  are  no  longer 
used  in  the  leverage  function,  the  plantar  flexors  and  adductors,  have 
become  atrophied,  a  change  that  is  made  evident  by  the  shrunken  calf. 
The  muscles  on  the  inner  border  of  the  foot  have  been  over-stretched, 
while  those  on  the  upper  and  outer  part  have  become  shortened  and 
contracted.  Such  a  foot  represents  an  extreme,  it  may  be  an  irreme- 
diable degree  of  deformity.  The  machine  is  completely  broken  down, 
it  can  no  longer  perform  its  proper  function,  it  is  even  less  efficient 
than  the  wooden  foot,  because  use  is  attended  by  discomfort. 

Etiology. — In  all  cases  the  actual  symptoms  of  pain  and  disability 
are  due  to  a  disproportion  between  the  burden  or  strain  and  the  ability 
of  the  machine  to  perform  it. 

This  theory  accounts  for  the  fact  that  the  weak  foot,  although  very 
common  in  childhood,  does  not  as  a  rule,  cause  troublesome  symptoms 
until  adolescence,  when  the  weight  and  strain  put  upon  it  are  increased. 
It  explains  why  the  foot,  which  may  be  fairly  normal  in  structure 
breaks  down  often  in  later  adolescence  or  early  adult  life  when  the  con- 
tinuous strain  of  regular  occupation  is  undertaken.  It  is  evident  also 
that  an  occupation  that  requires  the  long  continuance  of  the  passive 
attitude,  that  of  waiters,  cooks  and  bar-tenders  for  example,  exposes 
the  feet  to  greater  strain  than  one  which  permits  alternation  of  postures 
and  that  the  symptoms  are  likely  to  be  more  severe  and  the  deformity 
to  be  greater  among  those  who  are  obliged  to  labor  than  among  those 
who  are  not.  Over-work  or  strain,  of  occupation  or  otherwise,  may  be 
temporarily  disproportinate  because  of  general  weakness,  as  for  example, 
during  pregnancy  or  after  recovery  from  exhausting  disease  ;  or  because 
of  local  injury  or  disease  of  the  foot  itself  which  weakens  it  directly 
or  induces  improper  attitudes.  On  this  theory  one  may  very  easily 
explain  what  has  proved  such  a  stumbling  block  for  students,  viz.,  that 
there  is  no  constant  relation  between  the  degree  of  deformity  and  the 
severity  of  the  symptoms  ;  for  although  all  flat  feet  are  weak  feet  yet 
all  weak  feet  are  not  necessarily  painful  feet.  Pain  is  not  caused  be- 
cause the  foot  is  flat ;  it  is  a  symptom  of  progressive  deformity,  of 


512 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT. 


strain  and  injury  to  the  joints  ;  it  shows  that  the  foot  is  becoming  flat 
or  it  is  a  symptom  of  injury  that  the  weak  or  flat  foot  has  received. 
The  progress  of  the  deformity  may  be  temporarily  or  permanently 
checked  at  any  stage,  either  by  a  removal  of  the  exciting  cause  or  be- 
cause of  the  resistance  of  the  tissues  ;  then  the  pain  ceases.  On  the 
other  hand,  this  stability  may  not  be  attained  until  the  entire  sole  of 
the  foot  rests  upon  the  ground,  and  even  then  the  patient  may  suffer 
from  discomfort  and  pain. 

This  conception  of  the  foot  as  a  machine,  of  which  grades  of  efficiency 
may  be  recognized,  has  a  great  advantage  since  it  enables  one  to  per- 
ceive wherein  a  foot  is  weak  even  though  the  weakness  causes  no 
symptoms  whatever.  Thus  one  is  enabled  to  prevent  deformity  by 
teaching  the  patient  to  avoid  the  extra  strain  that  improper  attitudes 
entail,  and  to  strengthen  the  muscles  on  whose  ability  its  integrity  de- 
pends. Finally  from  this  standpoint  one  may  better  appreciate  the 
weakness  and  deformity  that  is  often  the  direct  result  of  improper 
shoes,  a  subject  that  will  receive  more  extended  consideration  elsewhere. 

Statistics. — A  brief  analysis  of  a  thousand  cases  of  so-called  flat  foot 
treated  at  the  Hospital  for  the  Ruptured  and  Crippled  will  represent 
fairly  the  points  of  general  interest  in  this  class  of  cases. 

The  Age  and  Sex  of  the  Patients. 


Age. 

Ten  years  or  less....... 

Ten  to  fifteen 

Fifteen  to  twenty 

Twenty  to  twenty-iive 
Twenty -five  to  thirty. 
More  than  thirty 


Males. 

Females. 

68 

30 

112 

87 

144 

83 

94 

53 

68 

41 

132 

88 

618 

382 

Total. 


98 

199 
227 
147 
109 
220 


1,000 


Foot  aflfected :  right,  133  ;  left,  138  ;  both,  729. 

In  fifty-eight  cases  the  cause  of  the  disability  appeared  to  be  injury, 
and  in  sixty-five  instances  it  was,  apparently,  due  to  rheumatism  or  to 
rheumatoid  arthritis.  The  symptoms  usually  appear  first  in  one  foot, 
and  as  a  rule,  they  are  at  all  times  more  marked  on  one  side.  Of  five 
hundred  and  sixty-nine  instances,  in  which  the  duration  of  symptoms 
was  recorded,  it  was  six  months  or  less  in  four  hundred  and  nine. 

The  age  of  the  patients  is  of  interest  as  bearing  on  the  question  of 
prognosis.  Four  hundred  and  twenty-six  were  between  ten  and  twenty 
years  of  age,  and  seven  hundred  and  eighty  were  less  than  thirty. 

Hospital  statistics  cannot  adequately  represent  the  subject  of  the 
weak  foot,  for  as  a  rule,  it  was  because  of  disability  and  pain,  not  for 
the  deformity  or  for  the  milder  type  of  symptoms,  that  these  patients 
applied  for  treatment.  In  the  larger  proportion  muscular  spasm  and 
rigidity  were  present,  in  two  hundred  and  thirty-four  cases  to  such  a 
degree  that  forcible  over-correction  was  advised,  an  operation  rarely 
necessary  in  private  practice. 


SYMPTOMS.  513 

It  is  in  childhood  that  the  prevention  of  subsequent  weakness  and 
deformity  is  of  the  first  importance,  yet  but  ninety-eight  children  of 
ten  years  of  age  or  less  are  recorded,  and  of  these  a  large  proportion 
were  brought,  not  for  weakness  or  deformity,  but  for  treatment  of  the 
symptomatic  in-toeing. 

Symptoms. — As  has  been  stated,  the  symptoms  of  the  weak  foot, 
although  similar  in  type,  vary  in  severity  according  to  the  local  con- 
dition and  the  disturbance  of  function,  the  work  to  be  performed,  and 
the  susceptibility  of  the  individual.  The  earliest  symptom  is  usually 
a  sensation  of  weakness  ;  the  patient  begins  to  recognize  as  familiar,  a 
feeling  of  discomfort,  of  tire  and  strain  about  the  inner  side  of  the  foot 
and  ankle  ;  sometimes  after  long  standing,  a  dull  ache  in  the  calf  of  the 
leg,  or  pain  at  the  knee,  hip  or  in  the  lumbar  region,  symptoms  more 
common  in  women  than  in  men;  or  after  over-exertion  a  momentary  sharp 
pain  radiating  from  the  point  of  weakness,  thus  the  patient  often  dates  the 
history  of  his  trouble  from  a  long  walk.  After  a  time  the  patient  may 
become  aware  that  he  is  accommodating  his  habits  to  his  feet ;  he  rides 
when  he  once  walked,  he  sits  when  he  once  stood,  he  no  longer  runs 
up  or  down  stairs  or  jumps  off  the  street  car.  His  feet  have  lost  their 
spring  as  he  expresses  it,  which  means  that  the  foot  is  no  longer  sup- 
ported and  controlled  by  muscular  activity  and  is  no  longer  used  as  a 
lever.  Not  infrequently,  early  symptoms  are  pain  and  tenderness  at 
the  center  of  the  heel,  explained  in  part  by  the  jarring  heel  walk  which 
is  always  assumed  when  the  foot  is  weak,  and  in  part  by  the  strain 
upon  the  attachments  of  the  deep  plantar  ligaments.  The  patient  may 
complain  that  he  cannot  buy  comfortable  shoes ;  the  reason  is  that  the 
weak  foot  under  use  is  changed  in  shape,  so  that  the  shoe  that  was 
comfortable  in  the  morning  compresses  the  foot  painfully  at  night ; 
thus  increasing  discomfort  from  corns,  bunions,  painful  great  toe  joints, 
and  deformities  of  the  toes  is  experienced.  Coldness  and  numbness, 
congestion  and  increased  perspiration,  caused  by  the  impaired  circula- 
tion and  weakness,  are  common  symptoms  in  this  class  of  cases. 
Actual  pain  is,  as  a  rule,  felt  only  when  the  foot  is  in  use ;  it  ceases 
under  temporary  rest  or  relief  from  disproportionate  work,  and  it  is 
this  remittance  of  symptoms,  together  with  the  fact  that  the  discom- 
fort is  usually  more  marked  in  damp  weather,  that  leads  so  often  to 
the  mistaken  diagnosis  of  rheumatism.  The  foot  is  weak  and  vulner- 
able ;  the  patient  recognizes  the  fact  that  he  has  what  he  speaks  of  as 
a  weak  ankle,  or  sprain,  or  gout,  or  rheumatism,  but  if  he  has  accom- 
modated himself  to  the  weakness,  but  little  discomfort  is  experienced. 
In  many  instances  such  relief  or  accommodation  is  impossible,  and  it 
is  therefore  among  the  working  class  that  one  oftener  sees  the  frank 
and  rapid  development  of  the  disability  and  deformity.  The  range  of 
motion  becomes  more  and  more  restricted  ;  the  habitual  attitude,  at 
first  exaggerated  to  deformity  only  under  the  influence  of  the  weight 
of  the  body,  remains  as  a  permanent  displacement  of  the  bones.  The 
weak  and  dislocated  foot  is  subjected  to  constant  injury,  to  what  may 
be  likened  to  a  succession  of  slight  sprains,  so  that  local  congestion, 
33 


514  DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT. 

tenderness  and  swelling  may  appear  together  with  muscular  spasm, 
rigidity,  and  pain  on  passive  motion.  Because  of  this  rigidity  of  the 
foot,  which  has  lost  the  power  to  accommodate  itself  to  inequalities  of 
the  surface,  the  patient  dreads  to  cross  a  rough  pavement,  for  every 
misstep  is  a  source  of  pain.  Another  symptom,  the  discomfort  felt  in 
changing  from  a  position  of  rest  to  activity,  which  is  usually  present 
in  slight  degree  at  every  stage,  now  becomes  more  prominent.  The 
patient,  after  sitting  or  on  rising  in  the  morning,  is  unable  to  walk, 
but  staggers  and  limps  for  several  minutes,  a  symptom  explained  by 
the  fact,  that  when  the  foot  is  at  rest,  there  is  a  partial  reposition  of 
the  displaced  bones,  which  must  be  again  forced  into  the  deformed 
posture  that  has  become  habitual.  The  local  tenderness  and  muscular 
spasm  are  increased  by  use,  so  that  the  patient  may  have  difficulty  in 
removing  the  shoe  at  night  and  the  symptoms  relieved  by  the  rest  of 
Sunday  become  progressively  worse  during  the  week.  The  pain  and 
discomfort  are  more  general  in  character,  and  are  often  referred  to  the 
dorsum  of  the  foot,  representing  muscular  rigidity  and  tension,  and  to 
the  ankle  wdiere  the  external  malleolus  is  grinding  out  a  facet  in  the 
projecting  os  calcis.  The  patient  may  now  complain  of  discomfort  in 
the  feet  and  cramps  in  the  legs,  even  when  in  bed,  and  the  appearance 
of  weakness,  awkwardness,  and  depression  of  spirits  may  be  so  notice- 
able that  the  case  is  sometimes  mistaken  for  serious  disease  of  the 
nervous  system. 

The  appearance  of  such  a  foot  has  already  been  described,  and  the 
effect  of  the  deformity  on  its  function  should  be  evident.  The  gait  is 
slouchy  and  cloddy,  what  has  been  spoken  of  as  the  pedestal  walk  : 
the  feet  are  simply  pushed  by  one  another,  in  the  attitude  of  eversion, 
the  knees  are  slightly  flexed  and  the  weight  is  borne  entirely  upon  the 
posterior  segment  of  the  foot.  The  muscles  have  atrophied,  the  foot 
is  cold  and  congested  from  its  continued  inactivity  and  it  usually  is 
bathed  in  perspiration.  A  certain  range  of  motion  remains  at  the 
ankle  joint  but  adduction  is  absolutely  restricted  by  the  shortened  and 
spasmodically  contracted  muscles  on  the  outer  and  upper  surface. 
This  type  represents,  of  course,  only  the  severe  variety  that  is  more 
likely  to  be  seen  in  hospital  than  in  private  practice ;  and  it  would 
seem,  were  it  not  for  the  evidence  to  the  contrary  which  the  histories 
of  the  patients  present,  that  the  nature  of  the  trouble  must  be  recog- 
nized at  a  glance.  But  in  the  milder  and  earlier  cases  the  diagnosis  is 
not  always  so  easily  made. 

Diagnosis. — In  all  cases  of  suspected  weakness  of  the  foot,  a 
thorough  and  orderly  examination  should  be  made,  not  only  of  its  ap- 
pearance, but  also  of  its  functional  ability  and  of  the  manner  in  which 
it  is  used.  Such  an  examination  is  not  merely  for  the  purpose  of  diag- 
nosis, which  is  usually  apparent,  but  in  order  that  the  amount  and 
character  of  the  temporary  or  permanent  changes  in  structure  and  func- 
tion may  be  properly  estimated. 

Attitudes. — One  begins  the  examination  by  noting  the  manner  of 
standing  and  walking.     The  heel  walk,  the  exaggerated  turning  out  of 


DIAGNOSIS.  515 

the  feet,  the  slouchy  gait  in  which  the  leg  is  never  completely  extended, 
in  which  the  power  of  the  calf  muscle  is  not  applied,  and  in  which 
the  essential  postures  of  the  foot  are  disused,  are  all  elements  of  weak- 
ness that  should  be  corrected  whether  they  cause  symptoms  or  not. 

DiSTRiBUTiox  OF  Weight  axd  Steaix. — The  distribution  of  the 
weight  of  the  body  and  the  habitual  use  of  the  foot  are  often  made  evi- 
dent by  examining  the  worn  shoe.  If  it  is  bulged  inward  at  the  arch 
or  worn  away  on  the  inner  side  of  the  sole,  it  shows  weakness.  (Fig. 
360.)  The  same  observations  are  then  made  on  the  bare  feet,  particu- 
lar attention  being  paid  to  the  line  of  strain  or  leverage;  thus  a  line 
drawn  down  the  crest  of  the  tibia  from  the  center  of  the  patella,  con- 
tinued over  the  foot,  should  meet  the  interval  between  the  second  and 
third  toes  ;  if  it  falls  over  or  inside  the  great  toe,  it  shows  that  the  foot 
is  working  at  a  disadvantage.      (Fig.  352.) 

Contour. — The  contour  of  the  foot  should  then  be  examined ;  its 
internal  border  should  curve  slightly  outward,  so  that  if  the  feet  are 
placed  side  by  side  with  the  toes  and  heels  in  apposition,  a  slight  inter- 
val remains  between  them  ;  if  this  slight  concavity  is  replaced  by  a 
noticeable  convexity,  when  weight  is  borne  the  foot  is  weak.  (Fig. 
357.)  This  change  in  contour  is  the  earliest  and  sometimes  the  only 
evidence  of  deformity.  The  arch  of  the  foot,  properly  protected  by 
the  muscles  and  by  a  proper  attitude,  sinks  but  slightly  under  weight ; 
there  is  a  slight  elasticity  only,  as  the  strain  is  thrown  more  to  the 
inner  side  of  the  median  line,  and  if  the  depression  is  marked  it  shows 
weakness. 

Bearing  Surface. — The  exact  amount  of  bearing  surface  may  be 
shown  by  an  imprint  upon  carbon  paper  or  by  smearing  the  sole  with 
vaseline,  then  as  the  patient  stands  upon  a  sheet  of  white  paper  the  outline 
of  the  foot  should  be  traced,  so  that  the  relative  size  of  the  imprint  to 
that  of  the  foot  may  be  shown  and  compared  with  the  normal  standard. 

Another  method  is  that  suggested  by  Lovett.  The  patient  stands 
upon  a  square  of  plate  glass  fixed  in  a  table,  so  that  by  means  of  a 
mirror  beneath,  the  bearing  surface  may  be  examined  under  different 
degrees  of  pressure  and  in  different  attitudes.     (Fig.  361.) 

The  Range  of  Motion. — The  balance  of  the  foot,  as  shown  by  the 
range  of  motion,  is  next  to  be  tested,  for  its  limitation  is  one  of  the 
earliest  signs  of  improper  attitudes  and  of  weakness.  This  range  of 
motion  varies  somewhat  within  normal  limits ;  it  is  usually  greater  in 
childhood  than  in  adult  life,  greater  in  the  slender  than  in  the  massive 
foot,  and  greater  in  the  foot  used  properly  than  in  one  that  is  not.  The 
first  test  is  applied  to  simple  dorsal  and  plantar  flexion  ;  the  leg  must 
be  fully  extended  at  the  knee,  the  line  of  strain  must  be  in  its  normal 
relation,  so  that  the  foot  may  be  neither  adducted  nor  abducted  and  the 
observation  must  be  made  on  its  outer  border. 

In  this  position  the  patient  should  be  able  to  flex  the  foot  from  ten 
to  twenty  degrees  less  than  the  right  angle,  and  to  extend  it  from  forty 
to  fifty  degrees  beyond  the  right  angle,  the  range  of  motion  being  from 
fifty  to  sixty  degrees.     (Figs.  336,  337.) 


518  DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT. 

By  far  the  most  important  test  is  that  of  the  power  of  adduction  or 
inversion  of  the  foot,  the  test  of  the  medio-tarsal  and  sub-astragaloid 
joints,  a  motion  in  which  the  os  calcis  is  drawn  forward  and  inward 
nnder  the  astragalus,  while  the  forefoot  is  flexed  about  its  head.  With 
the  leo-  extended  and  the  patella  pointing  forward  the  foot  is  turned 
inward  as  far  as  possible  ;  the  elevation  of  its  inner  border  or  supina- 
tion and  the  turning  in  of  the  heel  are  Avell  illustrated  in  Figure 
338  ;  the  actual  range  of  adduction  is  somewhat  difficult  to  measure, 
but  it  is  about  thirty  degrees.  Even  the  mild  and  early  cases  of  weak 
foot  usually  show  some  limitation  of  this  most  important  motion  and 
in  many  instances  it  is  completely  lost,  the  patient  turning  the  entire 
leg  in  the  effort  to  adduct  the  foot.  The  less  important  motion  of  ab- 
duction may  be  tested  also  (Fig.  339) ;  its  range  is  about  half  that  of 
adduction,  so  also  the  range  of  supination  or  inversion  of  the  sole  is 
nearly  twice  as  great  as  that  of  pronation  or  eversion  of  the  sole.  In 
other  words  the  internal  border  of  the  foot  can  be  raised  twice  as  far 
from  the  floor,  as  can  the  external  border.  The  range  of  passive  mo- 
tion is  then  tested  by  pushing  the  foot  in  all  directions.  The  range 
of  dorsal  flexion  is  from  five  to  ten  degrees  beyond  that  of  voluntary 
motion,  w^hile  passive  extension,  so  far  as  it  applies  to  the  ankle  joint, 
is  about  the  same  as  the  voluntary,  although  the  forefoot  may  be  still 
farther  bent  downward  at  the  medio-tarsal  joint.  The  limit  of  passive 
adduction  is  considerably  beyond  that  of  voluntary  inversion.^ 

Passive  motion  serves  several  purposes ;  contrasted  with  the  range 
of  voluntary  motion  it  shows  the  habitual  use  of  the  foot,  since  the 
motion  least  used  is  most  limited.  It  also  makes  evident  the  slight 
restriction  of  motion  and  the  presence  of  local  tenderness,  which,  even 
in  early  cases,  are  usually  present.  Thus,  if  pressure  is  made  just  in 
front  of  and  below  the  internal  malleolus,  at  the  astragalo-scaphoid 
junction,  and  at  the  same  time  the  foot  is  quickly  adducted,  the  patient 
will  complain  of  pain  at  the  point  of  pressure  and  of  a  feeling  of  con- 
striction and  tension  about  the  dorsum  of  the  foot,  before  the  normal 
limit  of  motion  is  reached.  When  the  foot  is  dorsi-flexed  the  plantar 
fascia  is  put  upon  the  stretch,  and  its  condition  may  be  noted,  for  a 
contracted  and  sensitive  plantar  fascia  may  cause  symptoms  of  discom- 
fort, that  may  induce  improper  attitudes  and  thus  predispose  to  further 
,  disability. 
^  Varieties  of  the  Weak  Foot. — This  mode  of  examination  will 
demonstrate  the  disability  and  permanent  change  in  the  machine, 
which  must  be  overcome  before  a  cure  can  be  accomphshed.  By  it 
one  will  learn  to  recognize  several  grades  of  weak  foot. 

1.  The  normal  foot  improperly  used,  as  shown  by  the  manner  of 
standing  and  walking. 

1  As  adduction  and  supination  and  abduction  and  pronation  are  always  combined, 
one  term  is  used  to  signify  the  movement  inward  or  outward  ;  thus,  supination  means 
adduction,  abduction  implies  pronation.  A  fixed  attitude  of  adduction  and  supination 
is  called  varus,  a  fixed  attitude  of  abduction  and  pronation  is  called  valgus.  Varus 
and  valgus  signify,  therefore,  deformity.  Thus  the  term  valgus  although  it  may  be 
properly  applied  to  designate  the  deformity  of  weak  foot  is  usually  reserved  for  the 
more  extreme  distortion  of  talipes.     (See  Figs.  338  and  339. ) 


EXTREME  TYPES  OF  WEAK  FOOT.  517 

2.  The  foot,  which  because  of  laxity  of  ligaments  or  insufficient 
muscular  support,  is  forced  by  the  weight  of  the  body  into  an  attitude 
of  deformity  ;  that  is,  in  which  the  foot  under  weight  falls  into  an 
abnormal  attitude  of  abduction  in  its  relation  to  the  leg,  as  evidenced 
by  the  inward  projection  of  its  inner  border  and  by  the  overhanging 
internal  malleolus,  showing  that  the  leg  has  been  displaced  inward  on 
the  foot.  As  a  rule,  there  is  sufficient  laxity  of  ligaments  to  allow  a 
depression  of  the  arch,  as  shown  by  the  imprint,  but  in  other  instances, 
although  the  arch  seems  lower  because  of  the  characteristic  attitude,  in 
which  the  leg,  as  it  were  overhangs  the  foot,  yet  the  imprint  shows 
that  there  is  no  increase  in  the'  area  of  bearing  surface.  Indeed  this 
may  be  even  smaller  than  normal ;  thus  an  individual  may  suffer 
from  so-called  flat  foot  whose  arch  is  actually  exaggerated. 

3.  The  weak  foot,  which  shows  typical  deformity  under  use  and  in 
which  the  range  of  voluntary  motion  is  somewhat  limited,  particularly 
in  the  direction  of  plantar  flexion  and  adduction.  Forced  motion  causes 
discomfort  and  pain,  indicating  a  certain  permanent  accommodative 
change  in  structure,  which  is  not  apparent  when  the  foot  is  not  in  use. 

4.  The  foot  which  presents  typical  and  permanent  deformity,  whether 
it  is  in  use  or  not,  and  in  which  the  range  of  both  voluntary  and  pas- 
sive motion  is  much  restricted.  In  all  of  these  varieties,  however,  the 
improper  functional  use  of  the  foot,  in  the  loss  of  active  leverage,  is 
very  evident  when  the  patient  walks. 

Limitation  of  Motion  and  Muscula^e  Spasm. — Limitation  of 
motion  is  caused  by  the  accommodative  changes  in  structure  to  the 
habitual  postures  or  to  the  deformity.  These  are  first  evident  in  the 
muscles  and  ligaments  and  finally  in  the  articular  surfaces  of  the  bones. 
Added  to  this  underlying  limitation  of  motion,  there  is  usually  a  certain 
amount  of  muscular  spasm,  which  varies  in  degree  with  the  local  con- 
gestion, irritation  and  inflammation  of  the  joints  and  tissues.  In  the 
quiescent  flat  foot  it  may  be  absent  but  on  renewed  injury  or  over-work 
of  the  weak  structure,  it  again  appears.  It  depends  also  upon  the 
irritable  condition  of  the  over-worked  and  contracted  abductor  mus- 
cles, practically  the  only  group  which  retains  functional  power ;  thus 
the  spasm,  as  has  been  stated  in  describing  the  severe  and  painful  type 
of  weak  foot,  is  greater  after  the  day's  use  and  relaxes  somewhat 
during  the  night.  The  degree  of  muscular  spasm  and  rigidity  corre- 
sponds with  the  intensity  of  the  symptoms,  but  by  no  means  with  the 
depression  of  the  arch  or  with  the  duration  of  the  deformity. 

Extreme  Types  of  Weak  Foot.  1.  Persistent  Abduction. — In 
one  type  of  rigid  foot  the  foot  is  twisted  outward  and  upward.  It 
may  be  pronated  to  such  an  extent  that  practically  the  weight  is  borne 
upon  the  heel  and  the  ball  of  the  great  toe.  In  such  instances  the 
astragalus,  although  rotated  inward  upon  the  pronated  os  calcis,  is,  of 
course,  not  plantar  flexed  nor  is  the  anterior  extremity  of  the  os  calcis 
depressed.  The  entire  foot  is  simply  held  in  an  attitude  of  extreme 
abduction  and  dorsal  flexion,  by  the  spasm  and  contraction  of  the  flexors 
and  abductors,  so  that  the  leg  must  be  bent  at  the  knee  and  inclined 


518 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT. 


Fig.  358. 


forward  to  brins  the  sole  to  the  ground.  Such  extreme  cases  are  un- 
common.  They  are  often  the  direct  result  of  injury,  so-called  chronic 
sprain,  and  when  the  deformity  is  reduced  the  arch  will  be  found  to  be 
exaggerated  in  depth.  Less  extreme  types  of  this  class  are  often  seen 
and  they  serve  to  emphasize  the  statement  that  the  most  important  dis- 
ability of  the  weak  foot  is  due  to  the  change  from  the  normal  relation 
between  the  leg  and  the  foot  and  not  to  the  depression  of  the  arch, 
which  is  in  most  instances  a  secondary  deformity. 

2.  Pes  Planus. — As  has  been  stated  already,  and  as  is  well  known, 
there  is  a  type  of  painless  flat  foot  sometimes  called  pes  planus  in 

which  the  flatness  of  the  foot  is 
more  noticeable  than  the  other 
components  of  the  deformity 
that  have  been  described.  This 
is  probably  the  result  of  in- 
herited laxity  of  ligaments  or 
of  rhachitis  or  other  form  of 
acquired  weakness  in  early  life, 
so  that  a  normal  arch  was  never 
present.  Such  a  foot  controlled 
by  normal  muscles,  may  be 
strong  and  efficient  but  it  is 
nevertheless  deformed,  and  it  is 
doubtful  if  its  pos.sessor  ever 
could  attain  the  grace  and  elas- 
ticity of  gait  possible  under  nor- 
mal conditions.  It  is  said  also, 
that  a  low  arch  is  normal  in 
certain  races,  for  example  the 
negro,  but  it  is  certain  that  the 
American  negro  is  not  exempt 
from  the  pain  and  disability 
incidental  to  the  broken-down 
foot,  whether  his  arch  was 
originally  low  or  not. 
It  is  evident,  of  course,  that  the  breaking  down  of  a  properly 
shaped  foot,  provided  with  normal  ligaments,  will  be  attended  by 
greater  pain  and  greater  disability  than  of  one  in  which  the  arch  was 
originally  low  and  of  which  the  ligaments  were  weak,  because  it 
is  during  the  progression  of  the  deformity  and  particularly  in  its 
early  stages,  that  such  symptoms  are  most  prominent.  When  the 
bones  of  the  arch  rest  upon  the  ground  or  when  final  stability  has 
become  assured,  pain  may  cease,  and  permanent  accommodation  to 
the  new  conditions  may  increase  the  ability  of  the  deformed  mem- 
ber. Such  an  outcome  might  be  quickly  accomplished  in  the  foot 
originally  flat,  while  in  the  other  instance,  the  symptoms  although 
remitting  from  time  to  time,  might  continue  during  the  life  of  the 
sufferer. 


Weak  feet  and  slight  knock  knees. 


WEAK  FOOT  IN  CHILDHOOD. 


519 


Weak  Foot  in  Childhood. 

There  can  be  no  doubt  that  in  many  instances,  the  origin  of  the 
weak  foot  may  be  traced  to  early  childhood.  Certainly,  deformities 
and  improper  attitudes  are  very  common  at  this  period,  and  it  is  much 
more  likely  that  they  are  ingrown  than  outgrown.  Actual  pain  from 
the  weak  foot  is  rare  at  this  age.  The  child  may  complain  of  fatigue 
and  may  be  weak  and  awkward,  but  it  is  usually  because  of  the  very 
evident  deformity,  rather  than  because  of  symptoms,  that  advice  is 
asked.  In  these  cases,  as  in  every  case,  the  habitual  attitudes  and  use 
of  the  feet  are  of  the  first  importance. 

Out  and  In  Toeing  as  Symptoms  of  the  Weak  Foot  in  Child- 
hood.— One  of  the  most  frequent  of  the  improper  postures  is  that  of 
exaggerated  outward  rotation  of  the  feet,  which  is  not  only  an  ungrace- 
ful attitude,  but  a  direct  cause  of  weakness  as  well.  The  opposite 
attitude  of  inward  rotation,  the  so- 
called  "  pigeon-toed  "  walk,  is  most  Fig.  359. 
offensive  to  relatives  and  friends,  and 
it  is  for  correction  of  the  attitude 
that  the  child  may  be  brought  for 
treatment.  The  attitude  is,  in  many 
instances,  a  sign  of  the  weak  foot, 
for  on  examination  the  bulging  on 
the  inner  side,  the  inward  rotation 
of  the  leg  in  its  relation  to  the  foot, 
and  the  flattened  arch,  show  very 
plainly  that  it  is  the  foot  and  not  the 
attitude  that  requires  treatment ;  in 
fact,  the  attitude  is,  in  this  class 
of  cases,  really  a  safeguard  against 
increasing  deformity  and  it  will 
correct  itself  when  its  cause  is  re- 
moved. Particular  emphasis  is  laid 
upon  this  point,  which  is  very  gen- 
erally over-looked,  because  the  rou- 
tine treatment  of  the  "  pigeon  toes  " 
in  these  cases  might  be  the  cause 
of  direct  harm. 

Weak  Ankles. — "  Weak  ankle  "  is  a  term  popularly  applied  to  the 
weak  foot  of  childhood,  in  which  the  foot  is  in  a  position  of  valgus 
when  in  use,  so  that  the  shoe  is  worn  away  on  its  inner  side.  Weak 
ankles  are  very  common  in  very  young  children  and  are  often  one  of 
the  results  of  general  weakness  due  to  defective  assimilation.  At  this 
age  the  foot  is,  in  addition,  usually  flat  (Fig.  358),  but  in  the  valgus 
or  weak  ankle  of  later  years  the  arch  is  often  practically  normal  in 
outline. 

Outgrown  Joints. — In  older  children  prominent  or  '^outgrown" 
joints  often  attract  the  mother's  attention  ;  the  internal  malleoli  appear 


Congenital  flat  foot.  Rigid  deformity  of 
an  extreme  type  illustrating  the  component 
abduction  and  obliteration  of  the  arch. 


520 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT. 


prominent  because  of  the  position  of  valgus,  or  because  of  the  eversion 
of  the  feet  the  malleoli  may  strike  against  one  another,  ^'interfere," 
and  thus  there  may  be  an  actual  hypertrophy  of  the  projecting  bones 
from  local  irritation. 

Another  type  is  the  long  slender  foot  in  which  the  scaphoid  bone  is 
prominent  because  of  the  strain  and  pressure  put  upon  it  by  the  im- 
proper attitudes ;  its  position  is  often  shown  by  the  point  of  wear  in 
the  leather  of  the  shoe.     (Fig.  357.) 

In  the  weak  foot  of  childhood,  although  restriction  of  voluntary  and 
passive  motion  may  be  present,  there  are,  as  a  rule,  but  little  local  ten- 
derness and  muscular  spasm,  and  as  has  been  said,  but  little  actual 
pain  ;  thus  it  differs  greatly  from  the  adult  type,  for  the  reason  that 
the  weak  foot  in  childhood  has  not  been  subjected  to  the  strain  of  con- 
stant occupation  or  to  the  burden  of  the  increased  weight  of  the  body. 
There  is  another  important  difference  also ;  the  foot  of  the  adult  is 

obliged  to  bear  greater  strain 
Fig.  360.  than  any  other  part,  and   al- 

though normal  in  structure  it 
may  be  over-strained,  so  that 
in  many  or  in  most  instances 
the  weakness  of  the  foot  may 
be  the  only  disability.  But  in 
childhood,  when  such  exciting 
causes  are  absent,  a  weak  foot 
is  very  often  a  local  indication 
of  general  weakness  and  loss 
of  tone. 

Gexeeal  Weakness.  — 
The  direct  effects  of  the  weak 
and  painful  foot  have  been  de- 
scribed in  detail.  It  must  be 
borne  in  mind  that  the  feet  are 
the  foundation  of  the  body,  and 
that  an  insecure  foundation  affects  the  entire  mechanism.  General 
ftinctional  weakness  and  awkwardness,  the  flat  chest,  round  shoulders  or 
other  curvatures  of  the  spine,  are  often  observed  as  accompaniments  or 
effects  of  weak  feet.  Thus,  as  a  rule,  the  systematic  treatment  of  any 
form  of  postural  weakness  must  include  the  treatment  of  the  feet  as  well. 
Recapitulation. — The  disability  and  deformity  of  the  weak  or  so- 
called  flat  foot  are  caused  by  a  disproportion  between  the  strength  of 
the  foot  and  the  weight  and  strain  to  which  it  is  subjected. 

The  foot  may  be  weakened  by  injury  or  disease ;  it  may  be  over- 
burdened by  the  body-weight,  or  over-strained  by  laborious  occupation, 
or  the  broken-down  foot  may  be  simply  one  indication  of  general  bodily 
weakness.  It  is  unnecessary  to  enumerate  all  the  various  factors  that 
singly  or  combined  lead  to  this  disability.  It  may  be  stated,  however, 
that  the  weak  foot  is  in  many,  or  most,  instances  the  only  disability 
that  demands  treatment.     Its  most  constant  predisposing  causes  are 


Flat  foot,  extreme  deformity  in  cliildliood. 


TREATMENT.  521 

improper  shoes,  and  the  mechanical  disadvantages  to  which  it  is  sub- 
jected'by  the  assumption  of  improper  attitudes. 

All  weak  or  flat  feet  are  mechanically  weak,  but  all  weak  feet  are 
by  no  means  painful  feet.  Pain,  the  symptom  of  over-strain  or  injury, 
bears  no  definite  relation  to  the  degree  of  deformity. 

In  certain  instances,  exaggeration  of  the  arch  may  be  combined  with 
persistent  abduction  of  the  foot ; .  in  others,  the  flattening  of  the  arch 
may  be  the  most  noticeable  deformity,  but  in  most  cases,  the  two  are 
combined  in  varying  degree.  And  as  each  deformity  is  an  evidence  of 
weakness,  it  seems  hardly  necessary  to  make  a  radical  distinction  be- 
tween the  two,  except  as  regards  prognosis.  For  the  abducted  foot  in 
which  the  arch  is  intact  is  almost  always  an  acquired  deformity  of 
short  duration,  whereas  in  the  case  of  the  foot  in  which  the  arch  is 
obliterated  the  deformity  usually  dates  from  early  childhood  and  it  is, 
therefore,  much  less  amenable  to  treatment  as  far  as  perfect  cure  is 
concerned. 

Treatment. — The  principles  of  the  treatment  which  leads  to  the 
permanent  cure  of  the  weak  and  deformed  foot  are  very  simple,  but 
the  application  varies  somewhat  according  to  the  grade  and  duration 
of  the  deformity.  The  object  of  treatment  is  to  so  change  the  weak 
foot  that  it  may  conform,  not  only  in  contour  but  in  habitual  attitudes 
and  in  power  of  voluntary  motion  to  those  of  the  normal  foot,  because 
complete  cure  is  impossible  unless  normal  function  is  regained.  The 
first  step  must  be,  therefore,  to  make  passive  motion  free  and  painless 
to  the  normal  limit.  In  other  words  the  obstructions  to  the  motion 
of  the  machine  must  be  removed  before  the  power  can  be  properly  ap- 
plied ;  for  the  increase  of  muscular  strength  and  ability,  on  which 
ultimate  cure  depends,  is  not  possible  while  motion  is  restrained  by  de- 
formity or  by  pain  or  by  adhesions  or  contractions. 

The  weak  foot,  because  of  inefficient  ligaments  and  muscles  unable 
to  hold  itself  in  proper  position,  must  be  supported,  in  many  instances, 
until  regenerative  changes  have  taken  place  in  its  structure.  Such 
support  is  necessary  to  retain  the  joints  in  proper  position,  and  to  hold 
the  weight  and  the  strain  in  proper  relation  to  the  foot,  otherwise  nor- 
mal motion  is  impossible.  When  these  essentials  are  provided,  the 
patient  may  cure  himself  by  the  proper  functional  use  of  the  foot, 
and  by  the  avoidance  of  attitudes  that  place  it  at  a  disadvantage. 

It  may  be  well  to  describe,  first,  the  treatment  that  must.be  applied 
to  all  classes  of  weak  foot  in  which  a  cure  is  to  be  attempted,  and  which 
by  itself  is  sufficient  in  the  milder  types,  before  calling  attention  to  the 
modifications  that  may  be  necessary  in  special  cases. 

The  Shoe. — In  practically  all  cases  it  will  be  necessary  to  provide 
the  patient  with  a  proper  shoe,  for  the  shoe  is  usually  the  direct  cause 
of  the  minor  deformities,  and  indirectly,  in  many  instances,  of  more 
serious  disability.  Indeed  most  of  the  deformities  and  disabilities  of 
the  foot  are  incidental  to  civilization  and  are  therefore  confined  to  the 
shoe-wearing  people.  The  direct  effect  of  the  ordinary  shoe  is  to  lessen 
the  size  and   balancing  power  of  the  fulcrum  by  cramping  the  toes 


522 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT. 


Fig.  361. 


together  while  the  high  heel  throws  more  strain  upon  the  arch  and  the 
ankle.  Indix'ectly  it  causes  deformities,  corns,  bunions  and  the  like, 
which  serve  to  make  active  movement  or  leverage  painful,  so  that  it  is 
replaced  by  the  passive  attitude. 

The  proper  shoe  should  contain  sufficient  space  for  the  independent 
movements  of  the  toes.  This  motion  is  illustrated  in  the  walk  of  the 
barefoot  child.  As  the  weight  falls  on  the  foot  the  toes  expand,  and 
as  the  body  is  raised  on  the  foot  they  contract.  The  important  lever- 
age action  of  the  great  toe  and  the  support 
afforded  by  it  to  the  arch  of  the  foot  have 
already  been  mentioned.  The  shape  of  the 
sole  should  correspond  to  the  shape  of  the 
foot  and  the  heel  should  be  broad  and  low. 
(Fig.  361.) 

The  prevention  of  distorted  toes  and  the 
discomforts  that  result  from  the  abuse  of 
the  foot  is  of  great  importance  in  child- 
hood, but  unfortunately,  little  children  are 
often  seen  wearing  shoes  of  the  shape 
usually  assumed  at  years  of  discretion.  In 
this  regard,  girls  suffer  more  than  boys  as 
women  do  more  than  men.  The  girl  who 
may  have  worn  comparatively  harmless 
shoes  until  the  age  of  ten  years  or  there- 
abouts, changes  suddenly  to  the  high  heel 
and  narrow  sole,  and  the  process  of  distor- 
tion begins,  the  amount  of  distortion  and 
the  degree  of  discomfort  depending  on  the 
amount  of  work  required  of  the  foot. 
Wide  soles  without  heels  should  be  worn 
as  long  as  possible  by  children  because  of 
the  greater  stability  and  because  the  high 
heel  limits  the  necessity  for,  and  therefore 
the  use  of,  the  entire  range  of  motion  of 
the  foot  and  ankle. 

Raising  the  Ixxee  Boedee  of  the 
Shoe. — A  simple  expedient  in  the  treat- 
ment of  the  weak  foot  and  an  aid  in  bal- 
ancing it  properly,  is  to  make  the  inner 
border  of  the  sole  and  heel  of  the  shoe 
slightly  thicker  in  order  to  throw  the  weight  toward  the  outer  side  of 
the  foot.  This  is  of  especial  importance  iu  the  treatment  of  the 
slighter  degrees  of  what  is  known  as  weak  ankle  but  it  is  always  of 
service  in  the  treatment  of  any  grade  of  weak  foot. 

Attitudes. — When  the  patient  stands,  properly  balanced  in  the 
proper  shoe,  his  attention  is  called  to  the  three  elements  of  weakness. 
He  is  instructed  to  guard  against  valgus  (Fig.  351)  by  throwing  the 
weight  on  the  outer  side  of  the  foot  (Fig.  352)  and  to  guard  against 


The  proper  relation  of  the  sole  to 
the  shape  of  the  foot.  A,  outline  of 
sole  ;  B,  outline  of  foot ;  C,  imprint 
of  foot. 


SUPPORT.  523 

abduction  by  holding  the  feet  parallel  with  one  another  in  walking 
(Fig.  §34) ;  the  significance  of  the  bulging  on  the  inner  side  of  the  foot 
is  pointed  out  to  him,  how  this  may  be  prevented  by  the  avoidance  of 
the  postures  just  indicated  and  by  aiding  the  arch  by  the  power  of  the 
great  toe.  The  importance  of  leverage  is  shown  him,  that  he  must  try 
to  press  down  the  sole  of  the  shoe  with  his  toes  and  employ  the  active 
lift  of  the  calf  muscles  by  fully  extending  the  leg  and  raising  the  body 
on  the  foot  from  time  to  time.  (Fig.  334.)  Finally,  he  must  avoid 
long  continuance  in  one  position,  especially  the  passive  posture,  w^hich 
simulates  the  attitude  and  deformity  of  flat  foot.  In  short  he  must 
be  instructed  in  the  mechanics  of  the  foot  and  taught  how  the  weak 
foot  may  be  protected  as  well  as  strengthened. 

Exercises. — It  is  important,  also,  to  show  the  patient  the  normal 
range  of  motion  of  the  foot,  motion  which,  if  restricted,  must  be  re- 
gained by  voluntary  and  passive  exercise.  Voluntary  exercise  should 
be  devoted  to  strengthening  the  adductors  and  plantar  flexors ;  thus 
the  foot  should  be  adducted  and  supinated  (Fig.  338)  over  and  over 
again  at  every  opportunity.  Tip-toe  exercises  are  especially  useful ; 
the  patient,  holding  the  feet  parallel,  raises  the  body  on  the  toes  twenty 
to  one  hundred  times,  resting  in  the  intervals  on  the  outer  border  of 
the  feet.  The  best  of  all  exercises  is,  however,  the  proper  walk,  in 
which  the  leverage  power  of  the  foot  is  employed  and  in  which  it 
passes  through  the  proper  alternation  of  postures.  (Fig.  334.)  Treat- 
ment by  massage  and  special  gymnastic  exercises  is  of  course  of  bene- 
fit, if  the  patient  can  command  it,  although  by  no  means  essential  to 
the  cure. 

Support. — In  many  instances  the  simple  treatment  that  has  been 
outlined  is  all  that  is  required  and  the  symptoms  of  tire  and  strain 
are  quickly  relieved,  but  in  the  more  advanced  type  of  disability  the 
patient  is  not  able  to  prevent  deformity  voluntarily,  consequently  a 
support  is  necessary  to  hold  the  foot  in  proper  position  and  to  relieve 
discomfort.  It  is  usually  necessary  in  the  treatment  of  the  weak  foot 
of  childhood,  because  one  cannot  command  the  aid  of  the  patient. 

In  selecting  a  support  for  the  weak  foot  the  nature  of  the  deformity 
that  is  to  be  prevented  must  be  borne  in  mind ;  that  the  acquired  flat 
foot,  for  example,  is  not  a  direct  breaking  down  of  the  arch,  as  is 
usually  taught,  but  a  lateral  deviation  and  sinking — a  compound  de- 
formity, as  has  been  already  described.  (Fig.  351.)  Thus  a  brace,  to 
be  efficient,  must  hold  the  foot  laterally  as  well  as  support  the  arch. 
But  it  must  not  prevent  the  normal  motions  of  the  foot,  and  thus  inter- 
fere with  the  increase  of  muscular  strength  and  ability,  on  which  ulti- 
mate cure  depends. 

The  supports  that  have  been  ordinarily  used  for  flat  foot  do  not  ful- 
fil the  conditions  ;  the  pads  and  springs  placed  beneath  the  arch  are 
intended  to  support  it  by  direct  pressure  without  regard  to  the  valgus 
or  the  abduction  ;  they  are  usually  ill-fitting  and  are  often  of  such 
length  and  shape  as  to  splint  the  foot  and  thus  to  restrict  its  motion. 
Leg  braces  which  control  the  valgus  do  not  often  hold  the  foot  accu- 


524 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT. 


rately,  and  their  weight  and  unsightliness  are  fatal  objections  to  their 
use  in  the  early  cases,  in  which  prevention  of  subsequent  deformity  is 
of  such  importance. 

A  brace  should  never  be  applied  to  a  deformed  and  rigid  foot  because 
it  is  unable  to  shape  itself  to  the  support ;  the  spasm  and  rigidity  must 
be  first  relieved  by  preliminary  treatment,  as  will  presently  be  de- 
scribed. 

The  Construction  of  the  Brace. — To  properly  construct  a  brace  to 
meet  these  conditions,  it  is  necessary  to  provide  the  mechanic  with  a 
plaster  cast  of  the  foot,  taken  in  the  attitude  in  which  one  wishes  to 
support  it.  Such  a  model  may  be  easily  and  quickly  made  in  the  fol- 
lowing manner. 

The  Plaster  Cast. — Seat  the  patient  in  a  chair ;  in  front  of  him 
place  another  chair  of  equal  height ;  on  it  lay  a  thick  pad  of  cotton 
batting  and  cover  it  with  a  square  of  cotton  cloth.  Put  about  a 
quart  of  cold  Avater  into  a  basin  and  sprinkle  plaster  of  Paris  on  the 

Fig.  362. 


The  attitude  iu  which  the  plaster  cast  should  be  taken.    In  the  reproduction,  the  chair  upon  which 
the  foot  is  resting,  has  been  removed. 

surface  until  it  does  not  readily  sink  to  the  bottom ;  then  stir. 
When  the  mixture  is  of  the  consistence  of  very  thick  cream  pour  it 
upon  the  cloth.  The  patient's  knee  is  then  flexed,  and  the  outer  side 
of  the  foot,  previously  smeared  lightly  with  vaseline,  is  allowed  to  sink 
into  the  plaster  and,  the  borders  of  the  cloth  being  raised,  the  plaster 
is  pressed  against  the  foot  until  rather  more  than  half  is  covered. 


THE  BRACE. 


525 


The  foot  should  be  at  a  right  angle  with  the  leg  and  the  sole  should 
be  in  the  plane  perpendicular  to  the  seat  of  the  chair.  (Fig.  362.) 
As  soon  as  the  plaster  is  hard  its  upper  surface  is  coated  with  vaseline 
and  the  remainder  of  the  foot  is  covered  with  plaster ;  the  two  halves 
are  then  removed,  smeared  lightly  with  vaseline  and  bandaged  to- 
gether. The  interior  is  dampened  with  soapsuds  and  it  is  then  filled 
with  the  plaster  cream. 

In  a   few  moments  the  Fig.  363. 

plaster  shell  may  be  re- 
moved, and  one  has  a  re- 
production of  the  foot, 
which,  when  properly 
made,  should  stand  up- 
right without  inclination 
to  one  side  or  the  other. 
In  many  instances  it 
will  be  of  advantage  to 
deepen  in  the  plaster 
model    the    inner     and 

outer     Seo'ments     of     the  a,  the  astragalo-scapbold  joint.    The  internal  flange  of  the 

1       .      ^      1  1  1  brace  should  rise  well  above  all  the  prominent  bones  to  a  point 

arch,    in    order    that    the        about  half  an  inch  below  the  malleolus. 

arch  of  the  brace  may  be 

slightly  exaggerated,  especially  at  the  heel,  so  that  the  depression  of 

the  anterior  extremity  of  the  os  calcis  may  be  prevented. 

The  Brace. — Upon  the  model  the  outline  of  the  brace  is  drawn  as 
illustrated  in  the  diagrams.  The  best  sheet  steel,  18  to  20  gauge,  cut 
after  the  pattern  is  moulded  upon  it  and  tempered,  so  that,  as  it  is  ap- 
plied for  the  purpose  of  preventing  deformity,  it  may  be  practically 

unyielding  to  the  weight  of  the 
Fig.  364.  body. 

It   will   be   noticed    that   the 

brace  clasps  the  weak  part  of  the 

foot  and  holds  it  together  ;    the 

broad   internal   upright    portion 

(Fig.  363)  covers  and  protects 

the  astragalo-scaphoid  junction, 

rising  well  above  the  scaphoid  ; 

the    external     arm    covers    the 

calcaneo-cuboid  junction  and  the 

outer    aspect   of  the  foot    to    a 

height  sufficient  to  hold  the  foot 

securely.    (Fig.  364.)    The  sole 

part  provides  a  firm,  comfortable  support,  yet,  reaching  only  from  the 

center  of  the  heel  to  just  behind  the  ball  of  the  great  toe,  it  does  not 

restrain  the  normal  motions  of  the  foot.     (Fig.  365.) 

The  brace  may  be  nickel  plated  and  japanned,  which  makes  a  smooth 
finish,  or  tin  plated,  or  galvanized,  which  makes  a  more  durable  cov- 
ering.    It  may  be  covered  with  leather,  or  an  inner  sole  may  be  placed 


B,  the  calcaneo-cuboid  junction.  The  external 
flange  extends  from  the  center  of  the  heel  to  a  point 
slightly  behind  the  base  of  the  fifth  metatarsal  bone. 


526 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT. 


Fig.  365. 


on  its  upper  surface ;  but  this  is  not  usually  necessary.  As  it  is  fitted 
to  the  foot,  it  finds  and  holds  its  own  place  in  the  shoe,  so  that  no  at- 
tachment is  required  ;  thus  it  may  be  changed  from  one  shoe  to  another. 
Not  only  does  it  hold  the  foot  laterally  and  from  beneath,  but  there  is 
an  element  of  suggestiveness  in  the  slight  leverage 
action  which  is  very  important. 

The  Positive  Action  of  a  Proper  Brace. — The 
patient,  instructed  to  throw  his  weight  upon  the 
outer  side  of  the  foot  and  wearing  the  shoe  which 
has  been  tilted  in  the  same  direction  by  thickening 
the  inner  border  of  the  sole  and  heel,  presses  down 
the  external  arm  and  thus  lifts  the  internal  flange 
against  the  inner  side  of  the  foot,  which  is  instinc- 
tively drawn  aw^ay  from  the  pressure  and  thus 
toward  the  normal  contour  ;  he  no  longer  everts  or 
turns  the  feet  outward  in  walking,  and  he  is  not 
likely  to  assume  the  passive  attitude,  because  of  the 
suggestive  lateral  pressure  of  the  support ;  thus  it 
becomes  a  positive  aid  in  the  physiological  cure. 

The  shape  of  the  brace,  in  general  like  that  of 
the  diagram,  is  modified  in  certain  cases ;  for  in- 
stance, the  entire  internal  aspect  of  the  foot  may  be 
weak  and  must  be  covered  by  the  internal  flange. 
In  very  heavy  subjects  the  sole  portion  must  be 
made  larger  although  this  is  a  detriment,  as  it  les- 
sens the  leverage  action  ;  other  slight  modifica- 
tions may  be  necessary  in  special  cases.  If  any  portion  of  the  rim  of 
the  plate  causes  discomfort,  the  edge  may  be  turned  away  slightly  at 
the  point  of  pressure  by  a  wrench.  After  a  few  days  the  patient  no 
longer  notices  the  presence  of  the  brace,  and  as  its  presence  in  the  shoe 
is  not  evident,  it  may  be  worn  indefinitely. 

It  is  usually  necessary  for  from  three  months  to  a  year  or  longer, 
according  to  the  condition  of  the  patient  and  the  strain  to  which  the  feet 
are  subjected.  The  brace,  properly  made  and  adjusted  under  the  proper 
conditions,  causes  no  more  pressure  or  discomfort  than  a  well  made 
shoe,  for  its  principle  is  quite  different  from  that  of  the  ordinary  sup- 
ports that  are  in  common  use,  to  which  this  objection  has  been  made. 
This  brace  supports  the  arch  primarily  by  preventing  abduction,  con- 
sequently its  pressure  is  first  felt  upon  the  lateral  aspect  of  the  foot,  a 
pressure  that  the  patient  can  relieve  by  improving  his  attitude.  The 
brace  should  afford  support  when  necessary,  and  at  all  times  suggest 
and  enforce  a  proper  attitude  ;  it  is,  however,  but  one  of  the  essential 
factors  in  the  general  scheme  of  treatment. 

In  the  treatment  of  children,  the  foot  should  be  moved  in  all  direc- 
tions but  particularly  in  dorsal  flexion  and  adduction  to  the  full  limit 
at  morning  and  at  night,  until  the  child  has  regained  the  normal 
muscular  power  and  ability.  Special  gymnastics  and  massage  are  al- 
ways desirable  and  they  may  be  necessary  in  certain  cases.     Bicycling 


C,  the  great-toe  joint 
D,  the  center  of  the  heel. 


THE  BIQID    WEAK  FOOT.  527 

may  be  cited  as  one  of  the  best,  and  roller  skating  as  one  of  the  worst 
exercisers  for  the  weak  foot.  A  year  is  about  the  time  required  for  a 
cure  of  the  weak  foot  in  childhood,  although  attention  to  the  shoes  and 
to  the  attitudes  must  be  continued  indefinitely. 

The  Rigid  Weak  Foot. 

One  may  now  contrast  with  these  mild  types  of  weakness  that  have 
been  described,  those  cases  of  extreme  deformity  in  which  the  symptoms 
are  disabling  and  in  which  the  foot  is  rigidly  held  in  the  deformed 
position  by  muscular  spasm  and  by  secondary  changes  in  its  structure. 
Such  cases,  often  considered  hopeless  as  regards  a  cure  or  even  relief, 
are  in  reality  the  most  satisfactory  from  the  remedial  standpoint,  and 
in  no  other  type  of  painful  deformity  can  so  much  be  accomplished  by 
rational  treatment  as  in  this  class.  The  deformity  must  be  considered 
as  a  dislocation  in  which  the  astragalus  has  slipped  downward  and  in- 
ward from  off  the  os  calcis,  which  in  turn  is  tipped  downward  and  in- 
ward and  into  a  position  of  valgus.  The  remainder  of  the  foot  is 
turned  outward,  so  that  the  relation  of  the  leg  and  the  forefoot  is  entirely 
changed ;  in  fact  the  forefoot  is  almost  entirely  disused.     (Fig.  366.) 

Corresponding  to  the  duration  of  the  disability,  one  finds  accommo- 
dative changes  in  the  soft  parts  and  in  the  bones,  but  such  changes  are 
by  no  means  as  marked  as  those  recorded  in  the  reports  of  autopsies 
which  have  been  made  in  cases  of  advanced  and  irremediable  deformity. 
In  fact,  by  far  the  greater  number  of  patients  are  young  adults  in 
whom  the  extreme  deformity  is  of  comparatively  short  duration,  and 
in  whom  complete  cure  is  possible. 

In  the  treatment  of  such  a  condition,  one  must  first  reduce  the  dis- 
location and  overcome  the  obstacles  that  contracted  muscles  and  liga- 
ments may  offer  to  free  and  normal  motion  ;  then  rest  must  be  assured 
to  the  injured  and  congested  parts  in  order  to  relieve  the  patient  from 
the  pain  from  which  he  has  suffered  so  long. 

Forcible  Over-correction. — By  far  the  most  effective  treatment  is 
forcible  over-correction  of  the  deformity,  under  ansesthesia.  When 
the  patient  is  under  the  influence  of  the  anaesthetic  the  muscular  spasm 
relaxes,  and  it  will  be  seen  that  this  accounts  for  about  half  of  the  re- 
striction of  motion,  the  remainder  being  caused  by  the  adaptive  changes 
that  have  been  mentioned.  One  now  endeavors  to  overcome  this  resi- 
dual obstruction  ;  and  to  assure  the  patient  against  a  relapse,  by  fixing 
the  foot  in  the  position  of  extreme  adduction  and  supination,  the  atti- 
tude directly  opposed  to  that  which  has  become  habitual. 

This  is  the  object  of  forcible  over-correction  as  the  first  step  in  the 
systematic  repair  of  the  disabled  mechanism  ;  its  principle  must  not  be 
confounded  with  forcible  correction  carried  out  with  the  object  of 
simply  remoulding  the  arch  of  the  foot,  or  in  which  the  simple  cor- 
rection of  the  deformity  is  the  object  in  view. 

One  first  extends  the  foot  forcibly,  then  flexes  it  to  the  normal  limit, 
then  abducts  and  adducts,  the  different  motions  being  carried  out  over 


528 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT. 


and  over  until  the  rigid  foot  has  become  perfectly  flexible.  In  cases 
of  long  standing  it  is  often  necessary  to  draw  the  patient  to  the  end  of 
the  table,  so  that  the  foot  may  be  taken  between  the  knees,  in  order  to 
supply  the  required  force  by  the  thigh  muscles.  This  forcible  manipu- 
lation is  accompanied  by  the  audible  breaking  of  adhesions,  and  the 
complete  disappearance  of  the  deformity.  In  certain  instances  it  will  be 
necessary  to  divide  the  tendo  Achillis  when,  for  example,  the  range  of 
dorsal  flexion  is  limited  by  resistant  accommodative  shortening  of  the 
calf  muscles,  or  when  there  has  been  very  great  pain  and  tenderness  at 
the  medio-tarsal  joint,  and  it  is  desired  to  remove  the  strain  of  lever- 
age completely ;  traumatic  cases  come  especially  under  this  head. 
Tenotomy  has  one  great  advantage,  it  necessitates  longer  fixation  in 
tlie  plaster  bandage,  and  gives  the  patient  the  benefit  of  rest,  and  the 


Fig.  366. 


Fig.  367. 


The   deformed    foot   before  The      over-corrected      foot, 

operation.     A,  the  projector!  of        showing    the    reversal    of    the 
the    displaced    astragalus    and        lines    of    displacement.       (See 
scaphoid  ;  B,  the  inner  malleo-        Fig.  368.) 
lus  ;   C,   the   mediotarsal  joint, 
showing  the  outward  displace- 
ment before,  the   inward   rota- 
tion behind,  this  point. 

opportunity  for  prolonged  after-treatment.  When  the  passive  range 
of  motion  has  been  regained,  the  foot  is  turned  downward,  then  inward 
and  upward  into  the  position  of  extreme  varus.  By  this  manipulation 
the  OS  calcis  is  drawn  under  the  astragalus  and  thrown  into  the  supi- 
nated  position,  and  the  scaphoid  is  flexed  about  and  under  the  head  of 
the  astragalus,  which  is  then  lifted  to  the  limit  of  normal  flexion.  The 
attempt  is  always  made  to  bring  the  extreme  outer  border  of  the  in- 
verted foot  up  to  a  right  angle  with  the  leg,  which  is  the  limit  of  nor- 
mal flexion  in  this  attitude.  The  foot,  thickly  padded  with  cotton,  is 
then  fixed  in  this  posture  of  club  foot  by  a  firm  plaster  of  Paris  band- 
age extending  to  the  knee.  (Fig.  3(38.)  Surprisingly  little  discom- 
fort, considering  the  force  that  it  is  sometimes  necessary  to  apply,  is 
experienced  after  the  operation.  The  familiar  and  often  intense  pain, 
from  which  the  patient  has  suffered  so  long,  is  entirely  relieved  by  the 


THE  RIGID    WEAK  FOOT. 


529 


Fig.  368. 


correction  of  the  deformity  ;  there  is  often  a  sense  of  tension  about  the 
outer  «ide  of  the  ankle  and  dorsum  of  the  foot,  but  this  is  not,  as  a  rule, 
of  long  duration. 

Functional  Use  in  the  Over-corrected  Attitude. — As  soon  as  possible, 
often  on  the  following  day,  the  patient  is  encouraged  to  stand  and 
walk,  bearing  his  weight  on  the  foot.  Walking  serves  two  purposes  : 
to  still  further  over-correct  the  deformity,  and  to  accustom  the  patient 
to  a  posture  entirely  different  from  that  so  long  assumed.  Meanwhile 
the  contracted  tissues  on  the  outer  side  become  thoroughly  over- 
stretched ;  the  weakened  ligaments  and  muscles  on  the  inner  side  are 
relaxed,  and  the  local  irritation  rapidly  subsides  under  the  rest  from 
the  constant  injury  to  which  the  foot  has  been  subjected. 

The  patient  is  not  confined  to  the  bed  or  house,  although  if  both  feet 
are  in  plaster  bandages,  crutches  are  of  course  necessary.     The  time 
that  the  feet  should  remain  in  the  over-corrected  position,  depends 
upon  the  duration  of  the  deformity  and  the  severity  of  symptoms,  or 
from  one  to  six  weeks,  the  usual  time 
being  about  three  weeks.    At  the  end 
of  two  weeks,  or  whenever  the  pa- 
tient can  support  the  weight  on  the 
plaster  bandage,  without  a  sensation 
of  discomfort,  it    is   removed ;    the 
foot  is  placed  in  the  normal  attitude, 
and  a  cast  is  taken  for  the  brace. 
Immediately  after  this  is  made,  the 
foot  is  returned  to  the  club-foot  po- 
sition   and    the   plaster    bandage  is 
re-applied.  When  the  brace  is  ready, 
the    plaster   bandage  is   finally  re- 
moved ;   the  foot  is  now  in  good  po- 
sition, and  in    many   instances    the 
arch  is  exaggerated  in  depth.     For 
the  first  few  days,  prolonged  soaking 
in  hot  water,  or  the  use  of  the  hot- 
air  bath,  with  subsequent  massage,  at 
intervals    during    the    day,  will    be 
found  useful  in  overcoming  the  swell- 
ing and  local  tenderness  that  may  re- 
main.    It  is  always  insisted  that  a 
new  shoe  of  the  Waukenphast  pattern 
shall  be  obtained,  the  sole  and  heel  of 
which  are  raised  a  quarter  of  an  inch 
on  the  inner  border,  to  aid  in  the  bal- 
ancing of  the  weak  foot.     The  brace  is  then  applied,  and  the  patient 
is  never  allowed  to  walk  without  its  support.      When  the  shoe  is  re- 
moved at  night,  he  is  instructed  to  turn  the  toes  in  and  to  bear  the 
weight  on  the  outer  side  of  the  foot  until  it  has  regained  its  strength ; 
in  other  words,  the  deformity  is  never  allowed  to  recur. 
34 


The  forcible  over-correction  of  flat  foot.  The 
proper  position  in  the  plaster  bandage. 


530  i         DISABILITIES  AND  DEFORMITIES  01    THE  FOOT. 

Systematic  Manipulation. — The  systematic  treatment  is  then  begun 
by  the  surgeon  and  the  patient,  the  first  essential  being  the  attainment 
of  free  and  painless  passive  motion  in  all  directions.  These  motions, 
which  have  been  so  long  restrained  by  deformity,  cannot  be  regained 
without  effort,  and  during  this  critical  stage,  treatment  must  be  carried 
out  by  the  surgeon  himself;  if  he  trusts  to  the  patient  or  to  his  friends, 
a  cure  is  out  of  the  question.  At  least  once  a  day  the  full  range  of 
motion  must  be  carried  out  to  the  normal  limit.  Three  motions,  ab- 
duction, flexion,  and  extension  are  usually  free  and  painless ;  but  the 
fourth,  that  of  adduction,  is  almost  invariably  resisted  by  the  same 
quality  of  muscular  rigidity  that  was  present  before  the  operation.  By 
far  the  most  effective  method  of  overcoming  this  resistance  is  con- 
ducted as  follows  :  the  patient  being  seated  in  a  chair,  the  surgeon  sits  or 
stands  before  him.  Let  us  suppose  that  the  left  foot  is  to  be  adducted 
or,  as  the  patients  express  it,  twisted.  The  surgeon  places  the  foot  be- 
tween his  knees ;  his  left  hand  encircles  the  heel,  the  fingers  grasping 
the  projecting  os  calcis  and  tendo  Achillis ;  the  base  of  the  palm  lies 
against  the  medio-tarsal  joint  on  the  inner  aspect  of  the  foot ;  the  right 
hand  grasps  the  outer  side  of  the  forefoot  and  toes  ;  then,  by  steady 
pressure  of  the  thigh  muscles,  the  forefoot  is  forced  downward  and  in- 
ward (adducted  and  supinated)  (Fig.  338)  over  the  fulcrum  formed  by 
the  projecting  palm,  which  lies  uj)on  the  left  knee,  the  fingers  holding 
the  heel  steadily  in  place.  This  inward  twisting  is  at  first  resisted  by 
a  mixed  voluntary  and  involuntary  muscular  spasm,  which  gradually 
gives  way  under  steady  pressure.  When  the  limit  of  adduction  has 
been  reached,  the  foot  is  firmly  held  until  all  pain  has  subsided  ;  then 
the  patient  is  instructed  to  attempt  voluntary  movements  while  the 
foot  is  guided  by  the  hands  ;  in  other  words,  the  patient  attempts  to  ad- 
duct  the  foot  while  the  surgeon  supplies  the  power,  which  in  all  cases 
of  this  type  has  been  completely  lost.  This  passive  manipulation  to 
the  extreme  limit  of  normal  adduction,  plantar  and  dorsal  flexion,  is 
continued  from  day  to  day  until  there  is  no  longer  a  sensation  of  pain 
or  tension  ;  for  as  long  as  there  is  the  slightest  spasm  or  painful  re- 
striction, so  long  is  the  voluntary  motion  limited,  cure  delayed,  and 
relapse  of  deformity  probable.  JDuring  active  treatment  the  patient, 
by  the  use  of  massage,  active  and  passive  motion,  is  constantly  working 
to  one  end,  namely,  to  regain  the  lost  power  of  voluntary  adduction. 

The  time  necessary  to  rest  the  feet,  to  overcome  the  local  irritation 
and  muscular  spasm,  to  regain,  in  part  at  least,  the  range  of  passive 
motion,  and  to  place  the  patient  in  the  same  position,  as  regards  a  cure, 
as  that  of  the  milder  type  of  deformity,  is  from  three  to  six  weeks. 
Usually  the  patients  are  told  that  a  month  will  be  necessary,  and  that 
at  the  end  of  that  time  they  may  return  to  work,  free  from  pain  and 
from  the  danger  of  relapse,  and  that  the  feet  will  constantly  grow 
stronger,  under  the  work  which  was  before  too  great  for  their  strength. 
The  time  necessary  to  reeducate  the  adductor  nuiscles  in  their  proper 
function  depends,  in  threat  degree,  ujion  the  intelligence  and  persistence 
of  the  patient.      Although  in  after-treatment  massage  and  special  exer- 


THE  RIGID   WEAK  FOOT.  531 

cises  are  of  benefit,  the  essentials  are  very  simple  ;  they  are  an  effective 
brace,  a  proper  shoe,  and  the  passive  manipulation  that  has  been  de- 
scribed, until  its  object  has  been  attained,  and  the  proper  walk,  the 
best  and  easiest  of  exercises.  Finally,  one  must  force  into  the  patient's 
understanding  the  method  of  protecting  the  weak  foot  by  the  alterna- 
tion of  strain,  and  by  proper  postures. 

Other  Varieties  of  Eigid  Weak  Foot. — The  foot,  which  is 
fixed  in  the  abducted  position  without  depression  of  the  longitudinal 
arch,  is  simply  one  variety  of  the  rigid  weak  foot,  which  should  be  treated 
in  the  same  manner.  It  may  be  stated  also,  that  a  very  large  propor- 
tion of  the  so-called  chronic  sprains  of  the  ankle  are  of  this  type,  and 
that  the  disability  will  yield  very  readily  to  treatment,  conducted  for 
the  purpose  of  restoring  impaired  function,  in  the  manner  that  has 
been  indicated. 

There  are  other  cases,  in  which  the  deformity  of  flat  foot  is  compli- 
cated by  rheumatoid  arthritis  or  chronic  rheumatism,  of  which  the 
evidence  is  seen  in  various  joints  but  in  which  the  pain  and  discomfort 
seem  to  be  concentrated,  in  the  feet,  which  are  absolutely  stiff  and  de- 
formed. In  such  cases  one  can  hardly  expect  a  complete  cure ;  but 
although  the  function  of  leverage  may  not  be  regained,  still  one  may 
hope,  by  overcoming  the  deformity,  to  hold  the  weight  of  the  body 
in  its  proper  relation  to  the  foot,  so  that  the  pain  of  a  progressive  dis- 
location may  not  be  added  to  the  pain  of  disease.  In  a  number  of 
instances  forcible  correction  has  been  employed  by  the  writer  in  cases 
of  this  type,  and  in  all,  the  improvement  in  the  general  condition, 
consequently  in  the  resistance  to  the  disease,  after  the  relief  of  the  local 
pain  and  discomfort,  has  been  very  great. 

Between  the  two  classes  of  cases,  the  mild  and  the  severe,  one  finds 
every  grade  of  deformity.  All  cases  in  M'hich  there  is  marked  muscular 
spasm,  local  tenderness  and  swelling,  require  temporary  rest ;  in  many 
instances,  simply  rest  from  functional  use  combined  with  massage  ;  in 
others,  rest  in  a  plaster  bandage  in  the  adducted  position.  In  the 
milder  and  ordinary  class  of  cases,  the  use  of  a  brace  and  shoe  will 
alone  relieve  spasm  and  pain,  and  the  range  of  motion  can  usually  be 
regained  by  manipulation,  passive  motion,  and  by  the  proper  use  of 
the  foot. 

Occasionally,  even  in  childhood,  one  may  encounter  marked  limita- 
tion of  normal  motion,  particularly  in  dorsal  flexion,  not  due  to  pain  and 
muscular  spasm  but  to  actual  shortening  of  the  muscle.  This  may  be 
the  accommodative  shortening  that  is  characteristic  of  long-standing  de- 
formity ;  in  other  instances  it  would  appear  to  be  the  result  of  a  slight 
and  unnoticed  neuritis  or  anterior  poliomyelitis,  which  has  resulted  in 
muscular  inequality.  If  the  contraction  does  not  yield  readily  to 
manipulation  or  to  mechanical  stretching,  forcible  correction  and  if 
necessary,  tenotomy  should  be  employed  in  the  manner  already  de- 
scribed ;  for  whatever  may  be  the  theory  of  its  causation,  it  is  again 
emphasized  that  obstruction  to  motion  in  any  direction  must  be  over- 
come before  a  complete  cure  is  possible. 


532  DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT. 

Adjuncts  in  Treatment. — It  must  be  apparent,  that  -in  many  in- 
stances, the  cure  of  the  weak  foot  is  out  of  the  question,  either  because 
of  the  want  of  energy  or  opportunity  on  the  part  of  the  patient,  or 
because  of  the  local  or  general  conditions,  types  familiar  in  out-patient 
practice. 

The  Thomas  Treatment. — In  such  cases,  raising  and  strengthening 
the  inner  side  of  the  shoe  by  the  wedge-shaped  leather  sole,  as  used  by 
Thomas,  splints  the  painful  foot  and  aids  in  relieving  the  strain. 

Plaster  Strapping. — If  the  symptoms  are  more  acute,  the  adhesive 
plaster  strapping,  as  advocated  by  Cottrell  and  Gibney  for  the  treat- 
ment of  sprains,  is  often  of  service,  although  it  is  applied  in  a  different 
manner,  and  with  a  somewhat  different  object  in  view.  One  end  of  a 
strip  of  adhesive  plaster,  about  fifteen  inches  long  and  three  inches 
wide,  is  applied  to  the  outer  side  of  the  ankle  just  below  the  external 
malleolus ;  the  foot  is  then  adducted  as  far  as  possible,  and  the  band 
is  drawn  tightly  beneath  the  sole  and  up  the  inner  side  of  the  arch  and 
leg,  and  is  stayed  in  this  position  by  one  or  two  plaster  strips  about 
the  calf.  Narrow  plaster  straps  are  then  applied  about  the  arch  and 
ankle,  in  the  figure-of-eight  manner,  and  a  bandage  is  applied.  The 
object  of  the  dressing  is  to  aid  in  holding  the  foot  in  the  proper  posi- 
tion, by  the  support  and  suggestiveness  of  the  plaster,  and  to  provide 
the  firm  compression  about  the  arch  that  is  always  agreeable  to  the 
sufferer  from  weak  foot.  This  treatment,  combined  with  the  built-up 
shoe,  is  often  very  effective  in  overcoming  the  acute  and  disabling 
symptoms  of  the  weak  and  injured  foot,  which  are,  as  has  been  stated, 
often  the  result  of  extra  strain  or  injury,  in  other  words  a  sprain  of  a 
weak  foot.  Consequently  when  these  symptoms  are  relieved,  the  pa- 
tient, who  has  become  habituated  to  the  weakness  and  deformity,  con- 
siders himself  cured. 

Operative  Treatment. — The  various  cutting  operations  for  the  relief 
of  flat  foot  do  not  call  for  extended  comment.  The  typical  operation, 
the  removal  of  a  wedge  from  the  astragalo-scaphoid  region,  aims  at  re- 
moval of  deformity  simply;  functional  cure  is  made  impossible  by  the 
destruction  of  the  medio-tarsal  joint.  It  would  hardly  seem  possible 
that  adhesion  between  the  astragalus  and  scaphoid  bones  could,  for  any 
length  of  time,  withhold  a  recurrence  of  deformity  of  the  nature  and 
origin  of  flat  foot,  and  in  all  cases  that  the  writer  has  examined,  in 
which  this  operation  had  been  performed,  there  was  still  local  tenderness 
and  muscular  spasm  and  even  relapse  of  the  deformity. 

The  operation  of  advancement  of  the  posterior  extremity  of  the  os 
calcis,  as  proposed  by  Gleich,  in  order  that  it  may  be  placed  in  relation 
to  the  leg  somewhat  like  that  of  a  Pirogoff*  amputation,  offers  little 
hope  of  ultimate  cure,  because  the  disability  is  not  due  to  primary  de- 
pression of  the  arch,  therefore  it  cannot  be  cured  by  exaggerating  its 
depth  in  this  manner.  The  most  innocent  and  rational  of  the  operations 
for  flat  foot  is  the  supra-malleolar  osteotomy  of  Trendelenburg,  in 
which  the  bones  of  the  leg  are  divided  above  the  ankle,  and  the 
distal  extremity  turned  inward,  with  the  aim  of  directing  the  weight 


THE  RIGID    WEAK  FOOT.  533 

upon  the  outer  border  of  the  foot.  In  practice,  the  operation  is  by  no 
means  always  successful,  while  the  bow-leg  deformity  that  results,  if 
the  object  is  attained,  is  an  unfortunate  accompaniment  of  the  treat- 
ment. It  may  be  mentioned  in  this  connection  that  fracture  at  the 
ankle  joint,  followed  by  faulty  union  in  a  position  of  valgus,  is  a  form 
of  traumatic  flat  foot  that  may  be  cured  by  this  operation.  In  operative 
treatment,  the  element  of  rest,  necessary  for  weeks  or  months,  must  be 
taken  into  consideration,  as  explaining  in  part,  the  immediate  favorable 
effect  of  whatever  procedure  is  adopted.  An  investigation  of  final  re- 
sults will  prove,  I  believe,  as  might  be  predicted  from  the  nature  of 
the  deformity  and  the  complex  structure  of  the  foot,  that  there  is  no 
short  and  easy  method  by  which  a  cure  may  be  attained. 

In  conclusion,  the  following  points  are  again  emphasized  :  Flat  foot 
in  its  surgical  sense,  is  a  compound  deformity,  in  which  the  abnormal 
relation  between  the  foot  and  the  leg,  causing  the  improper  distribution 
of  the  weight  and  strain,  and  disuse  of  normal  function,  is  of  vastly 
greater  importance  than  the  depression  of  the  arch,  which  has  given 
the  name  to  the  disability. 

The  weak  and  deformed  foot  can  be  cured,  but  only  by  the  applica- 
tion of  the  simple  principles  that  any  mechanic  would  apply  to  a  dis- 
abled machine  whose  structure  and  use  were  known  to  him ;  in  other 
words,  there  can  be  no  permanent  cure  of  weakness  and  deformity  un- 
less normal  function  is  regained,  or  effective  treatment  unless  it  has 
this  end  in  view. 

The  term  weak  foot  has  this  advantage  over  others  that  imply  de- 
formity, in  that  it  may  include  the  earliest  indications  of  disability.  Once 
weakness  is  recognized,  its  causes  may  be  analyzed  and  appreciated  at 
their  proper  value.  Flat  foot  is  a  particularly  objectionable  and  mis- 
leading term,  and  it  should  be  discarded,  or  at  least  used  only  to  de- 
scribe those  cases  to  which  it  can  properly  be  applied. 


CHAPTER    XXI. 

DISABILITIES   AND   DEFOEMITIES   OF   THE 
FOOT. — Continued. 

The  Hollow  or  Contracted  Foot. 

Synonyms. — Non-deforming  Club  Foot,  Talipes  Arcuatus,  Talipes 
Plantaris,  Talipes  Cavus. 

The  depth  of  the  arch  and  the  corresponding  area  of  the  bearing  sur- 
face of  the  sole  of  the  foot  vary  greatly  in  different  individuals,  and, 
although  marked  differences  in  appearance  and  function  are  possible 
within  a  normal  range,  yet,  as  a  rule,  the  low  arch  is  characterized 
by  a  certain  relaxation  and  weakness  of  structure,  while  the  exag- 
gerated arch  implies  a  corresponding  contraction  and  loss  of  normal 
elasticity. 

The  hollow  or  contracted  foot  may  be  divided  into  two  classes  ;  the 
SIMPLE  and  the  compound.  In  the  first  class,  the  simple  exaggeration 
of  the  arch  (talipes  arcuatus)  is  the  only  change  from  the  normal 
condition.  In  the  second,  the  high  arch  is  combined  with  a  certain 
limitation  of  the  range  of  dorsal  flexion  at  the  ankle  joint  (talipes 
plantaris — Fisher). 

Etiology. — The  simple  hollow  foot  may  be  an  inherited  peculiarity. 
The  depth  of  the  arch  may  be  exaggerated  by  the  habitual  use  of  high 
heels  (postural  equinus),  or  by  excessive  use  of  the  calf  muscle,  as  by 
professional  dancers. 

The  compound  variety,  in  which  the  hollow  foot  is  combined  with 
slight  equinus,  may  be  inherited  also ;  but  in  most  instances,  its  origin 
may  be  traced  to  a  mild  and  transient  form  of  anterior  poliomyelitis 
or  neuritis  in  early  childhood.  This  causes  temporary  weakness  of 
the  anterior  group  of  muscles  of  the  leg,  and  thus  a  slight  toe  drop, 
followed  by  secondary  contraction  of  the  tissues  of  the  sole  and  of  the 
muscles  of  the  calf.  In  the  history  of  many  of  these  patients  it  will 
be  found  that  after  recovery  from  scarlatina  or  other  contagious  or 
infectious  disease,  the  child  seemed  weak  or  awkward.  These  symp- 
toms became  less  marked  or  practically  disappeared ;  yet  a  trace  re- 
mained, although  not  of  sufficient  importance  to  call  for  treatment, 
until  adolescence  or  adult  life,  when  the  greater  strain  and  weight  put 
upon  the  feet  brought  to  light  the  latent  disability.  The  affection  may 
undoubtedly  develop  in  later  years  as  the  result  of  neuritis,  or  of  gout 
or  rheumatism.  It  may  be  caused  by  a  sprain  or  fracture  of  the 
ankle,  and  it  may  be  a  result  of  habitual  posture  to  compensate  for  a 
leg  shortened  by  injury  or  disease. 


SYMPTOMS. 


535 


Thg  exaggerated  arch  which  is  a  part  of  a  more  important  deformity, 
as  of  eqiiino-varus  or  calcaneus,  or  that  which  is  simply  a  part  of  the 
general  deformity  caused  by  diseases  of  the  nervous  apparatus,  does 
not  belong  to  the  class  of  disability  under  consideration. 

Symptoms. — The  simple  hollow  foot  often  exists  without  symptoms, 
in  fact  it  is  often  considered  as  a  particularly  well  formed  foot  rather 
than  a  deformity.  The  usual  complaint  in  these  cases  is  that  one  is 
unable  to  buy  comfortable  shoes  because  the  ordinary  shoe  does  not 
support  the  arch,  or  because  the  upper  leather  exerts  uncomfortable 
pressure  on  the  dorsum  of  the  foot.  The  convexity  of  the  dorsum  of 
course  corresponds  to  the  depth  of  the  arch,  and  in  many  instances,  the 

Fig.  369. 


The  coutracted  foot  of  slight  degree. 


cuneiform  bones  project  sharply  beneath  the  skin,  and  painful  pressure 
points  or  even  inflamed  bursse  in  this  locality  may  cause  discomfort. 

In  the  well-marked  cases  in  which  the  weight  is  borne  entirely  on 
the  heel  and  the  front  of  the  foot,  calluses  and  corns  often  form  at  the 
center  of  the  heel  and  beneath  the  heads  of  the  metatarsal  bones.  The 
patient  may  complain  of  neuralgic  pain  about  the  great  toe,  the  meta- 
tarsal arch,  or  in  the  sole  of  the  foot.  The  gait  is  often  ungraceful,  as 
the  patient  walks  heavily  upon  the  heels  with  feet  turned  outward.  In 
such  cases  "  the  ankles  may  be  weak  and  turn  easily."  In  the  more 
advanced  cases  of  this  type,  the  foot  may  assume  the  position  of  valgus 
when  weight  is  borne,  so  that  the  more  noticeable  symptoms  are  those 


536 


DISABILITIES  AND  DEFORMITIES   OF  THE  FOOT. 


of  the  weak  foot  or  so-called  flat  foot,  even  though  the  depth  of  the  arch 
is  exaggerated. 

Contracted  foot,  of  the  more  severe  grade,  is  almost  always  accom- 
panied by  a  certain  limitation  of  dorsal  flexion  ;  and  as  the  shortening 
of  the  plantar  fascia  is  often  more  marked  at  its  inner  border,  a  slight 
inversion  of  the  forefoot  or  varus  may  be  present  also. 

When  the  exaggerated  arch  is  combined  with  limitation  of  dorsal 
flexion  the  deformity  becomes  compound.  This  limitation  may  be  very 
slight,  or  it  may  be  well  marked  ;  and  a  slight  degree  of  permanent 

equinus   even,  may  be   present, 
Fig.  370.  but  SO  slight  that  it  does  not,  as 

a  rule,  attract  attention. 

This  type  of  the  contracted 
foot  was  first  clearly  described 
by  Shaffer  in  1885,  under  the 
title  of  "  non-deforming  club 
foot "  ^  and  later  by  Fisher,  of 
London,  as  "talipes  plantaris." 
The  symptoms  are  similar  to 
those  of  the  simple  hollow  foot, 
but  they  are  almost  always  more 
marked.  The  gait  is  awkward 
and  jarring,  the  feet  being  turned 
outward  to  an  exaggerated  de- 
gree ;  the  patient  is  easily  fa- 
tigued, and  often  complains  of 
the  weakness  about  the  ankle  and 
inner  side  of  the  arch,  character- 
istic of  the  weak  foot,  and  of 
sensations  of  tire  and  strain  in 
the  calf  of  the  leg.  The  discom- 
fort from  corns,  the  pain  referred  to  the  metatarsal  region,  the  great 
toe,  and  to  the  sole  of  the  foot  have  been  described  already. 

On  examination  the  exaggeration  of  the  arch  is  evident ;  and  an  im- 
print of  the  sole  shows  that  the  weight  is  borne  entirely  on  the  heel, 
and  on  the  heads  of  the  metatarsal  bones  which  may  be  very  promi- 
nent beneath  the  thickened  skin,  as  if  the  subcutaneous  pad  of  fat  had 
been  absorbed.  The  anterior  metatarsal  arch  is  often  obliterated,  and 
the  toes  are  usually  habitually  dorsi-flexed  at  the  first  phalanges,  the 
permanent  flexion  and  thus  pressure  against  the  leather  of  the  shoe 
being  shown  by  a  row  of  corns  upon  their  dorsal  surface.  (Fig.  370.) 
The  contracted  plantar  fascia  may  be  demonstrated  by  forcible  dorsal 
flexion  of  the  foot,  when  the  tense  bands,  in  many  instances  very  sen- 
sitive to  pressure,  may  be  felt  beneath  the  skin. 

On  testing  the  motion  of  the  foot,  the  limitation  of  dorsal  flexion, 
both  of  the  voluntary  and  the  passive  range,  will  be   evident.     In 
voluntary  flexion,  the  toes  are  drawn  up  and  the  tendons  are  plainly 
'N.  Y.  Med.  Eec,  May  23,  1885. 


Contracted  foot,  marked. 


OPERATIVE  TREATMENT.  537 

seen  qn  the  dorsum,  showing  the  effort  made  by  the  accessory  muscles 
to  overcome  the  abnormal  resistance. 

The  limitations  of  dorsal  flexion  may  be  demonstrated  in  the  manner 
suggested  by  Shaffer,  by  asking  the  patient  to  flex  the  feet,  while  stand- 
ing erect  with  the  back  to  the  wall,  when  in  spite  of  the  effort  made, 
"  the  feet  remain  glued  to  the  floor." 

Treatment. — In  the  ordinary  form  of  contracted  foot,  as  has  been 
stated,  the  disability  is  much  more  marked  than  the  deformity ;  and 
the  disability  is  due  to  secondary  changes  in  the  structure  of  the  foot, 
by  which  its  elasticity  is  impaired.  If  this  contraction  is  removed 
permanent  relief  will  follow.  If  the  simple  hollow  foot  (cavus),  or  the 
compound  type  (plantaris),  were  discovered  in  early  childhood,  massage 
and  methodical  stretching  would,  in  all  probability,  be  sufficient  to  re- 
lieve the  contraction ;  but  as  a  rule  no  symptoms  are  noticed  until  later 
life.  Even  then,  especially  in  the  simple  form,  they  are  often  slight  and 
may  be  relieved  by  a  shoe  with  a  broad  heel  and  a  high  (Spanish) 
arch  or  by  a  foot  plate  that  equalizes  the  pressure  on  the  sole. 

In  the  more  advanced  cases  of  the  milder  type,  methodical  mechan- 
ical stretching  of  the  parts  by  means  of  the  Shaffer  ^  "  traction  shoe  " 
may  elongate  the  tissues  sufficiently  to  relieve  the  symptoms ;  but  in 
the  more  resistant  cases  division  of  the  contracted  parts  and  forcible 
correction  of  deformity  is  indicated. 

Operative  Treatment. — The  patient  having  been  ansesthetized,  a  teno- 
tomy knife  is  introduced  beneath  the  skin  to  the  inner  side  of  the  central 
band  of  fascia.  This  is  divided  by  a  sawing  motion,  and  if  on  forced 
dorsal  flexion  other  tense  bands  appear  they  are  divided  also.  Forcible 
massage,  with  the  aim  of  making  the  foot  flexible  and  reducing  the 
depth  of  the  arch,  is  then  employed.  If  sufficient  force  cannot  be  em- 
ployed by  the  hands,  the  Thomas  wrench  may  be  used  as  in  the  treat- 
ment of  club  foot ;  the  object  being  to  elongate  the  foot,  to  remove  the 
contraction  and  thus  by  increasing  the  area  of  bearing  surface  to  relieve 
the  painful  pressure  on  the  heads  of  the  metatarsal  bones.  If  the  con- 
traction of  the  tendo  Achillis  can  not  be  overcome  by  forcible  manipu- 
lation it  may  be  divided.  The  foot,  held  in  an  attitude  of  dorsal  flexion, 
is  then  fixed  in  a  well-fitting  plaster  bandage,  a  thin  board,  shaped  to 
the  foot,  having  been  incorporated  in  the  bandage,  in  order  that  firm 
and  even  pressure  may  be  exerted  upon  the  sole.  As  soon  as  possible, 
often  on  the  following  day,  the  patient  is  encouraged  to  walk  about,  in 
order  that  the  pressure  of  the  body-weight  may  be  utilized  to  flatten 
the  foot  still  more,  while  its  tissues  are  in  a  yielding  condition. 

The  bandage  may  be  worn  for  six  weeks,  or  if  the  tendo  Achillis  has 
been  divided  until  its  repair  is  complete.  A  Avell-fitting  shoe  should 
be  worn,  and  methodical  massage,  and  stretching  of  the  tissues  should 
be  continued  as  long  as  the  tendency  to  deformity  remains.  By  this 
treatment  the  symptoms  may  be  relieved  and  in  many  instances,  a  re- 
turn to  the  normal  shape  and  function  can  be  assured. 

IN.  Y.  Med.  Jour.,  March  5,  1887. 


538  DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT. 

Weakness  of  the  Anterior  Metatarsal  Arch. 

Anterior  Metatarsalgia  and  Morton's  Neuralgia. — A  peculiar  spas- 
modic pain  about  the  fourth  toe  was  described  by  Morton  of  Phila- 
delphia long  before  its  predisposing  and  exciting  causes  were  under- 
stood. For  this  reason  a  description  of  the  symptoms  may  with 
advantage  precede  a  consideration  of  the  weakness  of  which  they  are 
usually  the  result. 

Typical  cases  of  Morton's  ^  painful  affection  of  the  foot  are  charac- 
terized by  a  sudden  cramp-like  pain  in  the  region  of  the  fourth  meta- 
tarso-phalangeal  articulation. 

The  pain  may  begin  as  a  burning  sensation  beneath  the  toe,  as  a  sud- 
den cramp  or  as  a  peculiar  feeling  of  discomfort  about  the  articulation 
that  increases  in  severity  until  it  becomes  almost  unbearable.  At  first 
the  pain  is  confined  to  the  neighborhood  of  the  affected  joint,  but  unless 
it  is  relieved,  it  radiates  to  the  extremity  of  the  toe  to  the  dorsum  of  the 
foot  or  up  the  leg.  In  many  instances  the  onset  of  the  pain  is  preceded 
by  the  sensation  of  something  moving  or  slipping  in  the  foot ;  in  some 
cases  the  pain  may  be  induced  by  sudden  movements,  missteps  or  long 
standing,  and  in  practically  all  the  cases  the  pain  is  felt  only  when  the 
shoes  are  worn.  The  frequency  of  the  recurrent  cramp  varies ;  in 
some  cases  it  is  felt  only  at  infrequent  intervals  ;  in  others  it  practically 
disables  the  patient.  When  the  cramp  habit  has  been  acquired,  very 
slight  causes  may  induce  the  pain,  for  example,  a  thin-soled  shoe,  a  hot 
pavement,  "  the  sticking  of  the  sock  to  the  foot "  and  the  like,  but, 
as  has  been  stated,  except  in  the  very  advanced  and  chronic  cases,  the 
pain  is  never  felt  except  when  the  shoe  is  worn. 

To  relieve  the  pain,  the  patient  removes  the  shoe,  rubs  and  com- 
presses the  front  of  the  foot,  flexes  and  extends  the  toes  and  the  like. 
After  the  cramp  is  relieved,  a  sensation  of  soreness  remains,  and  occa- 
sionally slight  swelling  may  appear,  but  in  most  instances  there  are  no 
external  signs,  although  the  affected  articulation  is  usually  sensitive  to 
deep  pressure  at  all  times. 

The  more  distinctive  term  anterior  metatarsalgia,  a  term  suggested 
by  Poulosson  of  Lyons  in  1889,  may  be  employed  to  include  Morton's 
neuralgia,  and  similar  symptoms  of  pain  and  discomfort  about  the 
anterior  metatarsal  arch.  For  in  many  instances,  the  cramp-like  pain 
is  referred  to  other  points,  for  example,  to  several  adjoining  joints,  or 
the  discomfort  caused  apparently  by  direct  pressure  on  the  bones  of 
the  weakened  arch  may  be  more  troublesome  than  the  irregular  attacks 
of  neuralgic  pain. 

Etiology  and  Pathology. — In  seventy-eight  cases  of  anterior  meta- 
tarsalgia in  which  the  location  of  the  pain  was  noted,  it  was  referred 
to  the  fourth  metatarso-phalangeal  articulation  in  sixty ;  to  the  third 
and  fourth  articulation  in  six  ;  to  the  second,  third  and  fourth  in  six, 
and  in  but  six  was  the  fourth  articulation  free  from  pain.  The  pain  is 
most  often  unilateral,  or  if  the  second  foot  is  affected,  it  is  usually  after 
a  considerable  interval. 

IT.  G.  Morton,  Am.  Jour.  Med.  Sci.,  Aug.,  1876. 


THE  ANTERIOR  METATARSAL  ARCH.  539 

The  affection  is  more  common  in  females  than  in  males.  Of  eighty- 
four  cases,  sixty-four  were  in  women  and  twenty  were  in  men. 

Anterior  metatarsalgia  is  not  an  affection  of  early  life,  the  average 
age  in  the  reported  cases  being  more  than  thirty  years.  It  is  rela- 
tively more  frequent  in  private  than  in  hospital  practice,  and  not  in- 
frequently the  patients  are  of  a  distinctly  nervous  type.  The  affection 
is  usually  extremely  chronic.  Occasionally  the  symptoms  may  cease 
spontaneously,  and  in  such  instances  a  particular  pattern  of  shoe  usually 
receives  the  credit  of  the  cure. 

Morton  considered  the  affection  to  be  a  painful  affection  of  the 
plantar  nerves  due  to  compression  or  pinching  by  the  adjoining  fourth 
and  fifth  metatarso-phalangeal  articulations.  This  comj)ression  was 
explained  by  the  anatomical  construction  of  the  foot,  i.  e.,  the  mobility 
of  the  fifth  metatarsal  bone  Avhich  allowed  it  to  roll  above  and  under 
the  fourth,  its  relative  shortness  which  allowed  the  head  and  base  of 
the  adjoining  phalanx  to  be  brought  against  the  adjoining  head  and 
neck  of  the  fourth  bone,  and  finally,  by  the  peculiar  distribution  of  the 
external  plantar  nerve  between  these  bones  that  made  it  or  its  fibers 
more  liable  to  injury.  This  natural  mobility  and  thus  the  predisposi- 
tion to  compression  might  be  exaggerated  by  a  sprain,  or  possibly  by  rup- 
ture of  the  transverse  metatarsal  ligament,  or  the  pain  might  be  induced 
by  wearing  tight  shoes,  but  in  many  instances,  no  cause  could  be  as- 
signed. On  this  theory,  Morton  advocated  excision  of  the  head  of  the 
fourth  metatarsal  bone  to  remove  the  point  of  counter-pressure.  This 
operation  has  been  performed  many  times,  but  practically  no  patho- 
logical changes  in  the  resected  bone  or  in  the  surrounding  parts  have 
ever  been  discovered. 

In  more  recent  years  the  true  significance  of  Morton's  neuralgia  and 
of  similar  pains  in  the  front  of  the  foot,  has  been  made  more  clear  by 
the  study  of  the  relation  of  weakness  of  the  anterior  transverse  meta- 
tarsal arch  to  the  symptoms.  Attention  was  first  called  to  this  point 
by  Poulosson  of  Lyons,  and  again  by  E,oughton,  Woodruff  and  others, 
and  in  a  much  more  thorough  and  convincing  manner  by  Goldthwait  ^ 
of  Boston,  in  1894. 

The  Anterior  Metatarsal  Arch. — If  one  examines  a  normal  foot,  one 
notices  that  the  two  middle  metatarsal  bones,  the  second  and  third, 
are  slightly  longer  and  on  a  higher  plane  than  their  fellows.  On  the 
sole  of  the  foot  the  arch  is  shown  by  the  depression  immediately  to  the 
outer  side  of  the  muscular  projection  of  the  great  toe  joint.  When 
weight  is  borne,  all  the  metatarsal  bones  are  on  the  same  plane  and  the 
arch  is  obliterated,  but  when  the  weight  is  removed,  the  arch  reforms 
with  a  certain  natural  resiliency.  In  walking  and  standing,  the  weight 
is  balanced  on  the  head  of  the  third  metatarsal  bone  as  is  shown  by  a 
thickening  of  the  skin  beneath  its  head,  but  the  strain  on  the  metatar- 
sal arch  is  relieved  somewhat  by  the  balancing  action  of  the  muscles 
about  the  first  and  fifth  metatarsal  bones,  the  inner  and  outer  supports 
of  the  arch,  and  by  the  active  assistance  of  the  toes  themselves.  When 
^  Boston  Med.  and  Surg.  Jour.,  Vol.  131,  p.  233. 


540 


DISABILITIES  AND  DEFORMITIES   OF  THE  FOOT. 


the  arch  is  weak  or  broken  down,  this  natural  resiliency  is  lost,  and, 
in  some  instances,  the  center  of  the  forefoot  is  not  only  depressed  but 
it  is  fixed  in  this  abnormal  attitude. 

In  the  ordinary  type  of  depressed  anterior  arch,  the  deformity  may 
be  shown  by  an  imprint  of  the  foot,  in  which  the  flabby  tissues  of  the 
depressed  arch  encroach  upon  the  clear  space  representing  the  longi- 
tudinal arch,  and  obliterate  what  Goldthwait  calls  the  reentering  angle 
to  the  outer  side  of  the  great  toe  joint,  which  in  the  normal  foot  indi- 
cates the  highest  point  of  the  metatarsal  arch.  In  many  instances 
however,  the  imprint  of  the  foot  subject  to  Morton's  neuralgia  may  be, 
to  all  intents,  normal  and  on  the  other  hand  depression  of  the  meta- 
tarsal arch,  one  of  the  very  common  results  of  improper  shoes,  may  be 
present,  yet  unaccompanied  by  pain  or  discomfort. 

Depression  of  the  anterior  arch,  the  result  of  the  loss  of  the  activity 
of  the  accessory  supports  of  the  arch,  predisposes  to  pain  because  of 


Fu;.  371. 


Position  of  the  fingers  corresponding  to  dorsi-flexion  of  the  toes,  an  attitude  in  which  lateral 

pressure  causes  pain. 

abnormal  pressure  upon  the  persistently  depressed  articulations  from 
beneath,  and  it  predisposes  to  pain,  as  the  writer  has  endeavored  ^  to 
explain,  because  the  metatarso-phalangeal  joints  of  the  arch,  which  is 
habitually  depressed,  cannot  escape  direct  lateral  compression,  if  it  is 
exerted  by  the  shoe  or  otherwise. 

This  point  may  be  illustrated  in  the  hand.  When  lateral  pressure 
is  applied,  the  hand  is  folded  together  and  the  anterior  metacarpal  arch 
is  increased  in  depth,  but  if  the  fingers  be  dorsi-flexed  so  that  it 
is  fixed  in  a  depressed  position,  then  lateral  compression  causes  great 
pain  at  all  the  articulations  (Fig.  371) ;  or  if  one  finger  is  dorsi-flexed  and 
the  corresponding  metacarpal  bone  is  thus  forced  below  the  level  of  its 
fellows,  lateral  compression  causes  pain  at  the  compressed  joint.  Or 
if  the  matacarpal  bone  of  the  little  finger  is  made  to  override  the 

1  N.  Y.  Med.  Eec,  August  6,  1898. 


ETIOLOGY  AND  PATHOLOGY.  541 

fourth,  lateral  pressure  causes  pain  usually  of  a  more  acute  character 
than  at  the  other  joints,  because  the  opportunity  for  direct  pressure  is 
more  favorable.'  Finally  if  firm  pressure  is  made  upon  one  or  the  other 
side  of  the  head  of  the  depressed  metacarpal  bone  of  the  dorsi-flexed 
finger  in  the  palm  of  the  hand,  a  point  of  sensitiveness,  representing 
apparently  the  digital  nerve,  can  be  made  out.  The  same  experiments 
may  be  tried  upon  the  foot  with  the  same  results,  and  it  would  seem 
to  make  clear  the  mechanism  of  the  pain  of  Morton's  neuralgia,  and 
the  allied  forms  of  discomfort  at  the  front  of  the  foot. 

Anterior  meta tarsalgia  is  in  most  instances  the  result  of  weakness 
or  depression  of  the  anterior  metatarsal  arch  as  a  whole  or  in  part,  and 
the  quality  of  the  pain  corresponds  fairly  to  the  form  of  weakness  or 
deformity.  If,  for  example,  the  entire  arch  is  rigidly  depressed,  as  in 
certain  rheumatic  aifections,  the  discomfort  is  likely  to  be  caused,  in 
great  degree,  by  the  direct  pressure  of  the  sensitive  depressed  meta- 
tarso-phalangeal  joints  on  the  sole  of  the  shoe,  or  if  lateral  pressure  is 
exerted  as  well,  the  more  acute  discomfort  or  pain  may  be  referred  to 
the  metatarsal  arch  in  general.  If  the  metatarsal  arch  is  weakened, 
depressed  and  broadened  but  not  rigid,  the  discomfort  is  often  referred, 
as  in  the  preceding  instance,  to  the  center  of  the  arch,  and  this  dis- 
comfort is  increased,  in  some  instances,  by  a  painful  callus  representing 
abnormal  pressure  at  this  point.  If  one  of  the  metatarsal  bones  falls 
below  its  fellows,  the  lateral  pressure  of  a  narrow  shoe  may  cause  neu- 
ralgic pain  at  this  joint,  but  in  many  instances,  in  which  the  anterior 
arch  is  depressed  the  patient  makes  but  little  complaint  of  pain.  In 
certain  instances,  more  particularly  those  of  Morton's  typical  neuralgia, 
the  foot  may  appear  to  all  intents  normal ;  in  such  cases  it  may  be  in- 
ferred that  the  sharp  and  characteristic  pain  is  caused  by  pressure  ap- 
plied to  the  over-riding  fifth  metatarsal  bone,  just  as  similar  pain  is  felt 
if  the  hand  is  suddenly  compressed  while  the  fifth  metacarpal  bone  is 
in  a  similar  position.  This  theory  is  the  more  probable  when  one  con- 
siders the  symptoms  ;  for  example,  the  sensation  of  something  slipping 
or  moving,  the  necessity  for  the  removal  of  the  shoe  to  flex  and  extend 
the  toes  and  to  compress  the  foot,  apparently  with  the  instinctive  aim 
of  replacing  a  depressed  arch,  or  a  misplaced  bone  in  the  arch.  It 
would  also  explain  how  the  shoe  may  be  the  most  direct  of  the  exciting 
causes  of  the  deformity,  in  that  it  compresses  the  forefoot,  and  throws 
more  weight  upon  it  by  elevating  the  heel.  If  the  arch  is  depressed 
or  becomes  depressed,  or  if  a  bone  in  the  arch  over-rides  another,  this 
compression  causes  the  symptoms. 

The  Influence  of  the  Shoe  in  Causing  Disability  and  Pain. — In  the 
etiology  of  pain  and  discomfort  about  the  anterior  arch,  one  must 
recognize  the  shoe,  not  only  as  the  direct  cause  of  the  pain,  but  also 
as  the  most  important  of  the  predisposing  causes  of  weakness  of  the 
anterior  arch,  of  which  the  pain  is  a  symptom,  since  it  compresses  the 
toes,  lifts  them  off  the  ground  by  its  "  rocker  sole,"  and  thus,  by  pre- 
venting their  normal  function,  throws  additional  strain  and  pressure 
1  This  anatomical  peculiarity  is  well  known  to  school  boys. 


542  DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT. 

upon  the  arch.  In  fact  in  a  very  large  proportion  of  feet  that  are 
supposed  to  be  normal  in  appearance  and  functional  ability,  the  toe& 
are  habitually  dorsi-flexed  in  a  claw-like  attitude,  that  shows  entire 
disuse  of  their  function  both  as  a  support  and  in  progression.  Women 
wear  shoes  with  narrower  soles  and  higher  heels  than  men,  and  this 
seems  the  most  reasonable  explanation  of  the  fact  that  they  are  more 
subject  to  the  affection. 

The  shoe  also  predisposes  to  habitual  elevation  of  the  fifth  meta- 
tarsal bone,  because  this  bone  almost  invariably  overhangs  the  narrow 
sole,  so  that  the  fourth  metatarsal  bone  becomes  the  outer  support  of 
the  arch,  and  is  almost  always  found  to  be  on  a  lower  level  than  the 
adjoining  bones  ;  a  fact  which,  together  with  the  natural  mobility  that 
may  have  become  increased  by  injuiyor  otherwise,  may  account  for  the 
location  of  the  pain  at  this  point  in  the  majority  of  cases.  Although 
in  certain  instances  a  neuritis  may  follow  direct  injury,  yet  this  assump- 
tion is  not  at  all  necessary  to  explain  the  symptoms.  Nor  is  it  likely 
that  the  peculiar  distribution  of  the  nerves  at  this  point  has  any  direct 
influence  on  the  pain,  for  the  nerve  supply  of  all  the  joints  and  all  the 
toes  is  practically  identical. 

Other  Factors  in  the  Etiology. — Besides  the  general  effect  of  the  shoe, 
and  the  possible  influence  of  inherited  predisposition  to  the  affection, 
which  seems  evident  in  certain  cases,  or  of  weakness  or  direct  injury  of 
the  anterior  arch,  one  recognizes  among  the  causes  or  complications  of 
anterior  metatarsalgia,  weakness  of  the  longitudinal  arch  or  flat  foot, 
which  may  be  combined  with  a  depression  of  the  anterior  arch.  Less 
often  the  longitudinal  arch  may  be  exaggerated  in  depth  and  the  dorsal 
flexion  of  the  foot  may  be  limited  by  a  shortened  tendo  Achillis,  thus 
more  pressure  is  brought  upon  the  front  of  the  foot.  In  these  cases, 
the  pain  may  be  increased  by  corns  or  calloused  skin  beneath  the  de- 
pressed bones  and  in  many  instances  the  discomfort  of  the  depressed 
arch  of  the  ordinary  type  is,  in  great  part,  caused  by  a  sensitive  corn  or 
fibroma  at  the  point  of  greatest  depression,  and  the  patient  may  be 
entirely  relieved  by  its  removal.     (See  contracted  foot.) 

Although  the  symptoms  of  anterior  metatarsalgia  may  be  explained 
in  most  instances  by  the  primary  effect  of  improper  shoes,  by  weak- 
ness and  abnormality  of  the  foot  itself,  and  by  the  local  sensitiveness 
of  the  parts  that  are  continually  subjected  to  strain  pressure  and  injury, 
vet  in  some  instances  the  symptoms  can  be  explained  only  by  local 
neuritis ;  in  others,  they  are  aggravated  by  gout  or  rheumatism  or 
general  debility,  and  as  has  been  stated  in  a  large  proportion  of  the 
cases  the  patients  are  of  a  distinctly  nervous  type. 

Treatment. — The  most  important  local  treatment  is  to  provide  the 
patient  with  a  proper  shoe.  This  shoe  must  be  of  proper  shape  with 
a  thick  sole,  so  broad  that  no  lateral  compression  of  the  toes  is  possi- 
ble, with  a  high  arch,  as  suggested  by  Gihney,  in  order  to  remove  a  part 
of  the  pressure  from  the  heads  of  the  metatarsal  bones,  and  a  low  heel. 

As  an  immediate  treatment,  a  firm  bandage  about  the  metatarsal  re- 
gion, as  suggested  by  Morton,  may  aid  in  supporting  the  metatarsal 


TREATMENT. 


543 


Fig.  372. 


arch,  or  better,  adhesive  plaster  strapping  may  be  applied  about  the 
metatarsus.  Beneath  or  slightly  behind  the  affected  joint  or  the  de- 
pressed arch,  a  pad,  preferably  an  oval  piece  of  sole  leather, 
about  one  inch  by  three-quarters  of  an  inch  in  size  and  one-quar- 
ter in  thickness  with  bevelled  edges,  may  be  fixed  to  the  sole  of 
the  foot  with  adhesive  plaster,  so  that  depression  of  the  arch  or  over- 
riding of  the  adjoining  bones  may  be  prevented.  This  pad,  suggested 
by  Poulosson  and  Goldthwait,  almost  always  relieves  the  pain,  and 
when  the  exact  place  has  been  ascertained,  it  may  be  fixed  to  the  sole 
of  the  shoe. 

As  a  rule,  however,  a  metal  support  will  be  found  to  be  more  com- 
fortable and  more  efficient.  This  may  be  constructed  of  light  steel  (19 
gauge)  upon  a  plaster  cast  of  the  sole  of  the  foot, 
of  which  the  natural  depressions,  indicating  the 
anterior  and  the  longitudinal  arches,  have  been 
somewhat  exaggerated.  The  anterior  extremity 
of  the  brace  is  made  as  wide  as  the  foot,  and  ex- 
tends forward  slightly  beyond  the  metatarso- 
phalangeal articulations.  The  brace  serves  to 
support  the  anterior  as  well  as  the  longitudinal 
arch.  If  there  is  slight  depression  of  the  longi- 
tudinal arch  it  may  be  further  corrected  by  rais- 
ing the  inner  border  of  the  heel  and  sole  of  the 
shoe,  but  if  it  is  more  pronounced  a  flat  foot 
brace  (Fig.  365)  may  be  employed,  whose  an- 
terior extremity  is  modified  to  support  the  met- 
atarsal arch,  as  is  shown  in  Fig.  372.  If,  on 
the  other  hand,  the  arch  is  exaggerated  and  if 
dorsal  flexion  is  limited,  treatment  with  the  aim 
of  relieving  this  deformity  will  be  necessary,  as 
described  under  "  contracted  foot."  When  the 
immediate  symptoms  of  pain  and  local  discomfort 
have  been  relieved,  the  patient  must  endeavor  to 
strengthen  the  natural  supports  of  the  arch  by 
proper  functional  use  of  the  foot,  and  by  regular 
exercise  of  the  muscles,  more  especially  by  metho- 
dical forced  flexion  of  the  toes,  as  this  motion  elevates  the  anterior 
metatarsal  arch.     (Fig.  373.) 

If  the  anterior  arch  is  rigidly  depressed  as  in  some  instances,  its 
flexibility  must  be  restored  by  manipulation  or  by  forcible  correction 
under  anaesthesia  before  a  brace  can  be  applied.  If  the  symptoms  are 
very  acute,  and  particularly  if  they  have  followed  direct  injury,  the 
parts  should  be  placed  at  rest  and  the  anterior  arch  should  be  elevated 
and  supported  by  a  properly  applied  plaster  bandage. 

In  chronic  and  resistant  cases,  or  when  conservative  treatment  cannot 
be  applied,  resection  of  the  neck  and  head  of  the  metatarsal  bone  at 
the  seat  of  pain  may  be  performed  as  advocated  by  Morton.  The  op- 
eration is  very  simple.     An  incision  is  made  over  the  dorsal  surface  of 


A  brace  for  anterior 
metatarsalgia.  A  iudicates 
a  point  beneath  the  fourth 
nietatarso-jihalangeal  artic- 
ulation wliich  is  elevated  in 
order  to  support  the  de- 
pressed articulation. 


544  DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT. 

the  joint,  and  the  bone  is  separated  by  bone  forceps.  The  toe  is  not, 
as  a  rule,  removed,  but  after  the  operation  it  slowly  recedes  between 
the  adjoining  metatarso-phalangeal  joints,  causing  a  rather  noticeable 
deformity.  The  operation  is,  as  a  rule,  successful,  but  in  the  majority 
of  cases  it  is  unnecessary. 

The  general  condition  of  the  patient  should  of  course  receive  atten- 
tion, and  local  applications,  electricity  and  the  like,  may  be  of  benefit 
in  special  cases. 

A  SENSITIVE  CALLUS  beneath  the  arch  may  require  removal,  and  in 
certain  cases  its  removal  may  be  the  only  treatment  required  other 
than  an  improved  shoe.  But  as  a  rule,  the  cause  of  the  callus  is  habitual 
depression  of  one  or  more  of  the  metatarso-phalangeal  articulations,  so 

Fig.  373. 


Exercise  for  the  weakened  metatarsal  arch. 

that  cure  can  only  be  assured  by  supporting  the  arch  and  by  strength- 
ening its  natural  supports  in  the  manner  already  described. 

Woodruff^  described  a  case  of  what  he  called  "incomplete  luxation 
of  the  metatarso-phalangeal  articulation"  in  which  the  symptoms, 
practically  identical  with  those  of  Mortion's  neuralgia,  are  ascribed  to 
an  upward  displacement  of  the  proximal  phalanx  of  the  fourth  meta- 
tarsal bone. 

Another  writer,  Guthrie,^  described  a  case  in  which  intense  pain 
followed  over-extension  of  the  third  phalanx  upon  the  second.  Such 
cases  are  extremely  uncommon  and  need  only  be  mentioned. 

Achillo -Bursitis. 

P^  Synonyms. — Achillodynia,  Achillo-bursitis  Anterior,  Retro-calca- 
neo  Bursitis. 

Under  the  title  of  achillodynia,  Albert,^  of  Vienna,  in  1893  called 
particular  attention  to  an  affection  characterized  by  pain  and  tender- 
ness   about    the   insertion  of  the    tendo   Achillis,  symptoms  usually 

'  N.  Y.  Med.  Eecord,  Jan.  18,  1887. 
2  Lancet,  March  19,  1892. 
3Wien  Med.  Presse,  Jan.  8,  1893. 


ACHILL  0-B  URSITIS. 


545 


caused  by  irritation  or  inflammation  of  the  small  bursa  lying  between 
the  insertion  of  the  tendon  and  the  bone.      (Fig.  374.) 

Etiology. — In  the  acute  cases,  the  cause  of  the  bursitis  often  appears 
to  be  a  strain  of  the  tendon  or  direct  injury,  as  the  symptoms  appear 
immediately  after  running  or  jumping  or  after  a  fall,  sometimes  after 
a  long  walk  or  bicycle  ride. 

In  the  subacute  cases,  the  symptoms  may  begin  almost  impercepti- 
bly, so  that  it  may  be  impossible  to  assign  a  direct  cause  other  than 
the  pressure  of  the  shoe,  aggravated  it  may  be,  by  an  exostosis  of  the 
OS  calcis  beneath  the  insertion  of  the  tendon  or  by  concretions  within 
the  bursa.  In  many  instances  rheumatism,  gout,  gonorrhoea  or  one  of 
the  infectious  diseases,  appear  to  be  associated,  directly  or  indirectly, 
with  the  onset  of  the  symptoms,  or  the  bursa 
may  be  secondarily  involved  in  tuberculous  dis-  Fig.  374. 

ease  of  the  os  calcis. 

Symptoms. — In  a  typical  case,  pain  is  felt  in 
the  back  of  the  heel  at  the  insertion  of  the 
tendon ;  the  pain  is  increased  by  use  of  the 
foot,  and  particularly  by  the  attitudes  in  which 
the  strain  on  the  part  is  increased,  as,  for  ex- 
ample, in  descending  stairs.  There  is  also  ten- 
derness on  pressure  about  the  back  of  the  heel 
on  either  side  of  the  insertion  of  the  tendon. 
In  most  cases,  a  slight  swelling,  often  more 
prominent  on  the  inner  than  the  outer  side  of 
the  tendon,  indicates  the  situation  of  the  bursa. 

In  the  chronic  cases,  the  enlargement  of  the 
bursa  is  very  noticeable,  and  in  addition,  the  en- 
tire posterior  aspect  of  the  heel  often  appears  to 

be  thickened.  This  is  due  probably  to  the  secondary  irritation  about 
the  fibrous  expansion  of  the  tendon  and  the  adjoining  periosteum.  In 
many  cases,  the  symptoms  are  pronounced ;  pain  is  often  felt  in  the 
bottom  of  the  heel  or  it  radiates  up  the  back  of  the  leg.  The  patient, 
unable  to  use  the  power  of  the  calf  muscle,  everts  the  foot  in  walking, 
thus  subjecting  the  arch  to  over-strain,  so  that  the  symptoms  of  the 
weak  foot  are  often  added  to  those  of  the  original  trouble.  Not  in- 
frequently however  the  two  affections  may  be  associated  from  the  be- 
ginning in  one  or  the  other  foot.  The  patient  complains  much  of 
stiffness  and  weakness  at  the  ankle  and  sub-astragaloid  joints.  In  the 
acute  cases,  or  in  acute  exacerbations  there  is  usually  burning  and 
throbbing  pain  characteristic  of  acute  inflammation,  but  in  the  sub- 
acute form  the  pain  is  slight,  and  is  troublesome  only  after  over-exertion. 

Pathology. — The  pathological  changes  do  not  differ  from  those 
found  in  and  about  other  bursse  under  similar  conditions.  In  the 
mild  cases  the  lining  membrane  is  simply  congested  and  the  cavity 
contains  serous  fluid.  In  the  chronic  cases,  the  walls  are  much  thick- 
ened,^ the  lining  membrane  is  fringed  and  reduplicated  ;  the  contents 


Bursa  between  the  tendo 
Achillis  and  the  os  calcis. 


35 


lEossler,  d.  Z.  f.  Chir.,  Bd.  42,  1  and  3. 


546  DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT. 

are  semi-solid,  and  sometimes  calcareous  masses  are  present.  Similar 
changes  are  found  however,  in  the  bursse  of  apparently  normal  sub- 
jects, so  that  the  condition  of  the  bursa  may  not  always  correspond 
to  the  character  of  the  symptoms.  Suppuration  of  the  sac  occa- 
sionally occurs,  and  it  may  be  the  seat  of  tuberculous  or  syphili- 
tic disease.  In  cases  of  long  standing,  the  parts  adjoining  the  bursa, 
the  expansion  of  the  tendon  and  the  periosteum  become  thickened 
so  that  the  bone  appears  to  be  increased  in  breadth  and  may  actually 
become  so. 

Treatment. — When  once  established,  the  affection  is  usually  of  a 
very  chronic  nature,  as  is  explained  by  the  strain  to  which  the  sensitive 
part  is  subjected  by  the  use  of  the  foot.  It  is  therefore  important 
to  apply  efficient  treatment  at  the  beginning  of  the  affection  if  an  op- 
portunity is  afforded.  Efficient  treatment  implies  absolute  rest,  and  in 
all  cases  of  any  severity,  particularly  those  of  acute  onset,  a  well-fitting 
plaster  bandage  should  be  applied  to  hold  the  foot  slightly  inverted 
and  at  a  right  angle  to  the  leg.  This  should  be  worn  until  all  symp- 
toms have  subsided.  In  very  mild  cases,  following  immediately  on 
a  strain  or  over-use,  simple  rest  with  the  application  of  heat,  massage, 
and  pressure,  may  be  efficient.  And  in  the  subacute  cases,  the  symptoms 
may  be  relieved  by  the  application  of  a  long  broad  band  of  adhesive 
plaster,  from  the  toes  over  the  back  of  the  heel  to  the  upper  third  of 
the  calf,  the  foot  being  slightly  plantar  flexed.  This  is  firmly  fixed 
by  narrow  strips  of  plaster  about  the  metatarsus,  the  heel  and  the  calf. 
By  this  means  pressure  is  exerted  upon  the  bursa,  and  much  of  the 
strain  is  removed  from  the  tendon. 

In  persistent  cases,  a  brace  may  be  used  with  advantage,  for  the 
purpose  of  preventing  strain  upon  the  tendon.  Two  lateral  uprights 
with  a  calf  band  and  padded  strap  that  crosses  the  upper  third  of  the 
leg  are  attached  to  the  shoe,  provided  with  a  stop  joint  at  the  ankle 
as  used  in  the  treatment  of  paralytic  calcaneus  to  prevent  dorsal  flexion. 
(See  talipes.)  As  the  patient  is  usually  sensitive  to  jar,  the  heel  of 
the  shoe  should  be  replaced  by  one  of  thick  rubber.  In  connection 
with  the  brace,  the  stimulation  of  the  cautery  and  the  pressure  of  the 
adhesive  plaster  strapping  seem  to  hasten  the  absorption  of  the  effu- 
sion in  and  about  the  bursa.  If  weakness  or  depression  of  the  arch 
is  present,  as  a  result  of  the  disability  or  combined  with  it,  a  foot 
plate  should  be  applied  (see  page  525),  and  general  affections,  with 
which  the  disability  is  sometimes  associated,  should  of  course^  receive 
attention. 

Operative  Treatment. — In  chronic  cases,  in  which  the  symptoms  are 
not  relieved  by  treatment,  the  enlarged  bursa  may  be  removed  by  an 
incision  on  one  or  both  sides  of  the  tendon.  A  plaster  bandage  is 
then  applied  and  is  continued  until  the  symptoms  have  subsided. 
Operative  treatment  is  of  course  indicated  in  acute  suppurative  in- 
flammation, in  tuberculous  disease,  or  if  an  exostosis  beneath  the  bursa 
or  concretions  within  the  sac  are  present,  as  shown  by  the  X-ray 
photograph. 


PAINFUL   HEEL.  547 


Achillo-Bursitis  Posterior. 


Tenderness,  pain  and  swelling  at  the  back  of  the  heel  may  be  due 
to  inflammation  of  the  small  superficial  bursa  that  lies  between  the 
tendon  and  the  skin.  The  cause  is  usually  injury  or  the  pressure  of 
the  shoe.  The  symptoms  resemble  somewhat  those  of  achillo-bursitis 
anterior,  but  the  swelling  is  more  superficial,  and  the  pain  is  caused 
by  direct  pressure  rather  than  by  tension  on  the  tendo  Achillis.  In  the 
ordinary  case,  removal  of  the  pressure  will  at  once  relieve  the  symp- 
toms, but  if  the  discomfort  is  considerable,  a  plaster  bandage  may 
be  worn  for  a  week  or  more. 

Sensitive  points  at  the  back  of  the  heel  are  usually  caused  by  the 
pressure  of  the  shoe ;  in  rare  instances,  prominent  points,  or  exostoses 
of  the  OS  calcis  are  present,  that  may  require  special  protection  or  re- 
moval. 

Strain  of  the  Tendo  Achillis. 

Not  infrequently,  and  usually  as  the  result  of  strain  or  over-use  of 
the  foot,  patients  complain  of  symptoms  similar  to  those  of  achillo- 
bursitis,  but  on  examination,  one  finds  that  the  pain  and  sensitiveness 
are  referred  to  the  tendon  itself.  There  is  no  swelling  at  its  insertion, 
or  pain  on  lateral  pressure  on  the  os  calcis.  The  sensitive  area  may 
be  as  high  up  as  the  junction  of  the  tendon  with  the  muscle,  and 
again,  the  mid-point  of  the  tendon  seems  most  painful. 

The  cause  in  some  cases  may  be  a  direct  strain  of  the  tendon  or  of 
the  muscular  fibers  near  its  origin,  or  inflammation  of  its  fibrous  cov- 
ering due  probably  to  the  same  cause.  The  treatment  is  similar  to 
that  of  the  milder  type  of  achillo-bursitis,  by  the  adhesive  plaster 
strapping,  by  rest,  and  later,  by  massage.     Recovery  is  usually  rapid. 

Painful  Heel — Calcaneo-Bursitis. 

Pain  referred  to  the  bottom  of  the  heel,  and  sensitiveness  to  pres- 
sure on  standing,  are  common  symptoms  of  the  weak  or  flat  foot. 
Pain  at  this  point  may  be  one  of  the  symptoms  of  achillo-bursitis  also. 
In  rare  instances,  the  painful  point  is  clearly  localized  and  is  confined 
to  a  small  area  in  the  neighborhood  of  the  inner  tuberosity  of  the  os 
calcis.  The  cause  of  the  symptoms,  in  such  cases,  may  be  an  inflamed 
bursa  lying  between  the  periosteum  and  the  fatty  tissue  of  the  heel. 
Such  bursse  may  contain  hard  substances  or  even  a  fasciculated  neu- 
roma.^ 

More  general  pain  and  tenderness  referred  to  the  heel,  is  often 
caused  by  the  direct  pressure  and  bruising  of  the  tissues  by  over-use 
of  the  feet. 

Treatment. — Treatment  must  be  directed  to  the  condition  of  which 
the  pain  is  a  symptom,  and,  as  has  been  stated,  it  is  most  often  one  of 
the  symptoms  of  the  weak  or  broken-down  arch.  If  the  tender  point  is 
^Brousses  &  Berthier,  Revue  de  Chir.,  Aug.,  1895. 


548  DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT. 

localized,  and  if  the  pain  is  increased  by  jars,  a  thick  rubber  heel  com- 
bined with  an  inner  sole,  so  cut  out  as  to  remove  the  direct  pressure 
on  the  sensitive  point,  will  often  relieve  the  symptoms.  In  persistent 
cases,  in  which  the  sensitive  point  is  distinctly  localized,  operative  in- 
tervention for  the  removal  of  the  bursa  is  indicated.  The  tissues  of 
the  heel  may  be  turned  back  in  a  horseshoe-shaped  flap  which  will 
allow  a  thorough  examination  of  the  affected  parts. ^ 

Sensitiveness  due  to  direct  contusion,  or  bruising  of  the  tissue  caused 
by  over-use,  must  be  treated  by  rest  and  by  change  of  occupation,  un- 
less a  reduction  of  the  body-weight  or  improvement  in  attitudes  re- 
lieve the  symptoms. 

Plantar  Neuralgia. 

Synonym. — Plantalgia. 

Pain  referred  to  the  sole  of  the  foot,  and  sensitiveness  to  pressure 
on  the  plantar  fascia,  are  usually  symptomatic  of  the  contracted  foot 
(cavus)  ;  less  often  such  symptoms  accompany  the  weak  or  broken- 
down  arch. 

Pain,  tenderness  and  thickening  of  the  fascia  sometimes  follow  in- 
jury (rupture  of  the  fascia),^  and  a  similar  condition  has  been  de- 
scribed by  Franke  as  one  of  the  sequelae  of  influenza.^ 

Treatment. — Pain  in  the  sole  of  the  foot,  symptomatic  of  the  con- 
tracted or  of  the  weak  foot,  may  be  relieved  by  the  treatment  of  the 
conditions  of  which  it  is  a  symptom.  In  the  rare  instances  in  which 
the  fascia  is  itself  injured  or  diseased,  local  rest,  as  afforded  by  the 
plaster  bandage,  is  indicated  until  the  acute  symptoms  have  subsided. 

Erythromelalgia. 

Wier  Mitchell  *  has  described  a  series  of  cases  characterized  by  attacks 
of  heat,  redness,  pain  and  often  swelling  of  the  soles  of  the  feet.  Of  27 
cases  all  but  two  were  in  women,  many  of  whom  were  of  a  nervous  or 
neurasthenic  type.  The  affection  appears  to  be  a  form  of  vaso-motor 
disturbance.  Disturbances  of  the  circulation  and  burning  pain  in  the 
soles  of  the  feet  are  common  symptoms  of  the  weak  foot  and  of  allied 
affections,  but  simple  erythromelalgia  unaccompanied  by  disability  of 
this  character  is  uncommon.  It  deserves  mention  however  as  a  pos- 
sible explanation  of  symptoms  in  obscure  cases.^ 

Hallux  Rigidus. 

Synonyms. — Hallux  Flexus,  Painful  Great  Toe. 
Hallux  rigidus  is  a  painful  affection  of  the  great  toe  joint,  character- 
ized by  restriction  of  motion,  particularly  of  the  range  of  dorsal  flexion. 

iDuplav,  Clin.  Cliir.  del' Hotel  Dieu.  Serie,  1897. 

^Lederiiose,  Verhand.  der  Deut.  G.  fur  Chir.,  XXIII. ,  Kong,  1894. 

3Archiv  f.  Klin.  Chir.,  Bd.  49,  1895. 

4  Am.  Jour.  Med.  Sci.,  Vol.  76,  1878. 

5  Prentiss,  Trans.  Am.  Ass'n  Physicians,  Vol.  XII.,  1897,  p.  303. 


HALLUX  BIGIDUS. 


549 


Fig.  375. 


lu  advanced  cases,  the  first  phalanx  may  be  slightly  plantar  flexed 
together  with  its  metatarsal  bone,  hence  the  name  hallux  flexus,  ap- 
plied by  Davies-Colley,  who  first  described  the  affection. 

The  restriction  of  motion  may  be  complete,  as  implied  by  the  term 
rigidus ;  the  joint  appears  unduly  prominent  or  enlarged,  usually 
slightly  congested,  and  pressure  or  forced  movement  causes  pain. 

The  symptoms  of  which  the  patient  complains  are  a  burning'or 
throbbing  pain  in  the  joint,  increased  by  standing  and  particularly  by 
walking,  because  of  the  enforced  movement  of  the  stiff  and  painful 
articulation.  In  many  cases  there  is  no  actual  deformity  of  the  joint 
or  other  change ;  the  restriction  of  motion  is  much  less,  and  the  symp- 
toms are  correspondingly  slight. 

Etiology. — Typical  hallux  rigidus  is  most  common  in  adolescence, 
and  it  is  very  often  associated  with  the  weak  or  broken-down  foot. 
In  such  cases,  the  toe  is  crowded  into  the  narrow  part  of  the  shoe,  and 
is  thus  subjected  to  lateral  and  to  longitudinal  pressure  as  well  as  to 
the  additional  strain,  that  the  attitude,  characteristic  of  the  weak  foot, 
throws  upon  it.  In  some  cases  the  habitual  plantar  flexion  of  the 
toe  may  be  the  result  of  an  instinctive  eflbrt  to  support 
the  weak  arch  (hammer  toe  flat  foot — Nicoladoni).  In 
other  instances  hallux  rigidus  is  caused  directly  by 
traumatism  ;  as  by  stubbing  the  toe,  by  kicking  a  hard 
object,  or  by  other  strain  or  injury.  The  aflection  ap- 
pears to  be,  primarily,  a  form  of  periarthritis,  caused 
by  injury  or  pressure.  The  restriction  of  motion  is  in 
part  due  to  muscular  spasm,  and  in  part  to  the  irrita- 
tive and  accommodative  changes  in  the  ligaments  and 
tendons.  In  more  advanced  cases  changes  in  the  car- 
tilage and  shape  of  the  articulating  surfaces,  due  to  dis- 
use of  function,  and  to  pressure  and  friction,  may  be 
present. 

Treatment. — If  the  rigid  and  painful  joint  is  not 
associated  with  the  weak  arch,  it  may  be  relieved  by 
providing  the  patient  with  a  proper  shoe,  which  ex- 
erts no  pressure  on  the  sensitive  part.  Motion  of 
the  joint  may  be  lessened  by  increasing  the  thickness 
of  the  sole,  or  if  necessary,  it  may  be  entirely  restricted 
by  the  insertion  of  a  brace  of  tempered  steel  between  the-  two  layers 
of  the  sole,  as  shown  in  the  diagram.  If,  as  in  some  instances,  the 
rigid  and  flexed  joint  is  associated  with  rigid  flat  foot,  both  defor- 
mities may  be  over-corrected,  under  anaesthesia,  and  retained  in  this 
position  by  the  plaster  bandage,  as  a  preliminary  treatment. 

If  the  milder  type  of  painful  joint  is  associated  with  the  ordinary 
weak  foot,  the  treatment  of  the  latter  condition  will  usually  relieve  the 
symptoms.  In  this  class,  particularly  among  the  poorer  patients,  the 
shoe  may  be  raised  on  the  inner  side,  and  the  sole  stifl^ened  by  means 
of  the  wedge-shaped  sole  recommended  by  Thomas,  as  already  de- 
scribed in  the  treatment  of  the  weak  and  flat  foot.     If  painful  motion 


The  dotted  out- 
line  shows  the 
shape  of  the  steel 
splint  that  may 
be  inserted  in  the 
sole  of  the  shoe  for 
hallux  rigidus. 


550 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT 


is  restricted  and  the  exciting  causes  of  the  disability  are  removed,  re- 
lief of  the  symptoms  is  usually  immediate.  In  the  chronic  cases,  in 
which  the  pathological  changes  are  more  advanced,  excision  of  the 
joint  may  be  necessary. 

Painful  Great  Toe  Joint  in  Older  Subjects. 

A  similar  condition  of  the  joint  is  sometimes  found  in  older  sub- 
jects. In  many  instances  the  foot  is  well  formed,  and  the  restriction 
of  motion  in  the  joint  is  very  slight ;  yet  forced  dorsal  flexion  causes 
pain  and  long  standing  or  walking  causes  much  discomfort,  particu- 
larly a  dull  ache  in  the  joint  and  sharp  neuralgic  pain  referred  to  the 
terminal  phalanx.  In  some  cases,  the  onset  of  the  symptoms  may  be 
ascribed  to  a  long  walk,  or  "  mountain  climb,"  in  others  to  wearing 
tight  shoes,  and  in  some  instances,  no  definite  cause  can  be  assigned  by 
the  patient.  In  such  cases,  the  symptoms  are  often  supposed  to  be 
■evidences  of  gout  or  rheumatism  but  although  the  local  discomfort  may 

Fig.   376. 


Simple  congenital  varus,  adduction  without  supination — a  form  of  pigeon  toe. 

be  aggravated  by  a  predisposition  to  sucli  diseases,  yet  no  relief  can  be 
obtained  by  medication  unless  it  is  combined  with  the  local  treatment 
that  has  been  described  in  the  preceding  section.  The  relief  aiForded 
by  such  treatment  alone,  proves,  in  many  instances,  that  the  aifection 
is  purely  local  in  its  character.      (Fig.  375.) 

As  has  been  mentioned,  pain  referred  to  this  joint  is  a  common  symp- 
tom of  the  Aveak  foot,  and  of  the  contracted  foot  as  well.  It  is  also 
caused  by  simple  pressure  on  the  joint,  and  by  the  use  of  improper 
shoes  which  force  the  toes  into  the  abducted  position. 

Pain  directly  beneath  the  great  toe,  and  sensitiveness  to  pressure 
about  the  sesamoid  bones  seem  to  indicate  an  inflammation  of  the  ten- 


HALLUX  VALGUS.  551 

don  sheath  or  local  periarthritis.  If  the  discomfort  is  persistent,  the 
sesamoid  bones  may  be  removed.  As  a  rule,  such  symptoms  occur 
only  in  combination  with  pain  or  deformity  of  the  great  toe  joint. 

Hallux  Varus. 

Adduction  of  the  great  toe  is  not  infrequent  in  infancy,  and  it  may 
be  associated  with  a  slight  degree  of  varus  deformity.  (Fig.  376.)  The 
peculiarity  attracts  the  mother's  attention  because  of  the  difficulty  of 
drawing  on  the  socks.  In  many  instances  the  muscles  seem  abnormally 
developed,  and  the  toe  appears  to  be  somewhat  prehensile  in  its  move- 
ments. 

Treatment. — The  abnormal  mobility  may  be  checked  by  inclosing 
the  toes  with  a  narrow  strip  of  adhesive  plaster  ;  in  any  event  the 
ordinary  shoe  may  be  depended  upon  to  correct  any  residual  deformity 
of  this  character.  If  the  adducted  toe  is  combined  with  varus,  it  repre- 
sents a  slight  degree  of  club  foot  that  must  be  corrected  in  the  ordinary 
manner.      (See  talipes.) 

Pigeon  Toe, 

Congenital  hallux  varus  forms  one  variety  of  what  is  known  as 
pigeon  toe,  or  the  habitual  turning  in  of  the  feet  in  walking.  The 
inward  rotation  may  be  due  also  to  bow  legs,  or  it  may  be  an  effect 
of  congenital  talipes  that  remains  after  the  cure  of  the  deformity,  or  of 
the  exceptional  variety  of  coxa  vara,  in  which  the  depressed  necks  of  the 
femora  are  turned  forward.  In  most  instances  pigeon  toe  in  childhood  is 
symptomatic  of  weakness  either  of  the  arch  of  the  foot  or  of  the  knees 
(genu  valgum).  In  such  cases,  it  is  a  conservative  effort  of  nature  that 
serves  to  check  further  deformity,  and  it  needs  no  treatment  other  than 
that  which  may  be  applied  to  the  weakness  of  which  it  is  a  symptom. 

In  the  exceptional  cases,  in  which  the  posture  is  not  symptomatic  of 
weakness  or  the  effect  of  deformity,  the  sole  of  the  shoe  may  be  raised 
slightly  on  the  outer  border.  This  will  correct  the  attitude  in  the 
milder  type,  if  combined  with  instruction  and  training.  In  rare  in- 
stances, the  in  toeing  seems  to  be  caused  by  limitation  of  the  range  of 
outward  rotation  at  the  hip  joints,  a  restriction  that  must  be  overcome 
by  systematic  stretching  of  the  contracted  parts.  In  these  and  in  the 
more  obstinate  cases  of  the  simple  type  apparatus  may  be  applied,  sim- 
ilar to  that  used  in  the  after-treatment  of  congenital  club  foot,  to  hold 
the  feet  in  the  proper  attitude.  (Fig.  377.)  It  must  be  borne  in  mind 
that  the  proper  attitude  of  the  feet  is  one  of  parallelism,  not  of  outward 
rotation,  and  that  slight  pigeon  toe  will  as  a  rule  correct  itself  as  the 
child  grows  older. 

Hallux  Valgus. 

Hallux  valgus  is  a  deformity  in  which  the  great  toe  is  turned  out- 
ward to  an  exaggerated  degree.  Outward  deviation  of  the  toe  is  so 
common,  owing  to  the  use  of  improper  shoes,  that  it  is  not  recognized 


552 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT 


Fig.  377. 


as  a  deformity^  at  least  from  the  popular  standpoint,  unless  the  joint 
appears  to  be  much  "  enlarged  "  forming  a  so-called  bunion. 

Hallux  valgus  is  practically  a  partial  dislocation  of  the  phalanx 
upon  the  metatarsal  bone.  In  well-marked  cases,  the  metatarsal  bone 
is  adducted  or  turned  inward  so  that  an  abnormal  interval  separates  its 
head  from  its  fellows,  while  the   phalanx  is  displaced  outward  and 

articulates  only  with  the  outer  condyle. 
The  angle  thus  formed,  or  more  prop- 
erly the  inner  condyle  of  the  adducted 
metatarsal  bone,  makes  the  prominent  or 
"outgrown  "joint.  (Fig.  382.)  This  pro- 
jects sharply  beneath  the  skin,  and  is  ex- 
posed to  injury  and  to  the  pressure  of  the 
shoe  ;  thus  a  bursa  develops  beneath  the 
skin,  while  a  corn  or  callus  forms  on  its 
superficial  surface.  The  projecting  bone, 
covered  by  the  irritated  bursa  and  the 
thickened  skin,  makes  up  the  bunion. 

In  many  instances  the  other  toes  are 
displaced  outward,  in  the  direction  cor- 
responding to  that  of  the  great  toe,  or 
this  may  be  rotated  on  its  long  axis  and 
lie  above  or  beneath  its  fellows. 

Pathology. — The  pathological  changes 
are  such  as  usually  follow  deformity,  dis- 
use of  function,  and  injury.  The  car- 
tilage on  the  exposed  condyle  atrophies, 
the  sesamoid  bones,  together  with  the 
flexor  tendon,  are  displaced  outward,  the 
tissues  on  the  outer  side  undergo  accom- 
modative shortening,  while  those  on  the  in- 
ner side  are  correspondingly  lengthened 
and  attenuated.  The  surface  of  the  bone 
beneath  the  irritated  periosteum  is  often 
roughened  and  irregular,  and  exostoses 
may  form  about  the  condyle,  and  thus  ag- 
gravate the  effects  of  the  external  pres- 
sure. 

Etiology. — The  deformity  is  the  direct 
effect  of  shoes  that  are  too  narrow  and 
of  improper  shape,  and  in  some  instances 
too  short  for  the  foot,  so  that  the  great 
toe  is  subjected  to  lateral  and  longitudinal  pressure.  The  deform- 
ing effect  of  the  shoe  is  increased  if  the  arch  is  weak,  so  that  the 
toe  is  forced  forward  into  the  narrower  part  of  the  shoe  when  the 
foot  is  in  use.  The  deformity  may  be  increased  by  injury,  or  by  the 
changes  that  follow  gout,  rheumatism,  or  rheumatoid  arthritis,  and 
in  rare  instances,  the  distortion  may  be  the  direct  result  of  such  dis- 


An  appliance  constructed  of 
leather  bands  and  elastic  webbing 
for  the  correction  of  in  toeing.  Name 
of  the  inventor  unknown. 


OPERATIVE  TREATMENT.  553 

eases;,  but  all  other  factors  are  of  slight  importance  when  compared  to 
the  deforming  influence  of  the  ordinary  shoe.  The  deformity  begins 
at  a  very  early  age ;  it  advances  more  rapidly  during  adolescence,  but 
the  symptoms  do  not  often  become  troublesome  until  later  years.  Both 
toes  are  affected,  as  a  rule,  although  the  deformity  and  its  accompany- 
ing symptoms  are  usually  more  marked  on  one  side. 

Symptoms. — As  has  been  stated,  the  slighter  grades  of  deformity 
are  not  recognized  as  such,  and  it  is  usually  because  of  the  pain  due  to 
the  irritating  corn  or  bursa,  and  incidentally,  because  of  the  outgrown 
joint,  that  the  patients  apply  for  treatment. 

Treatment. — The  symptoms  in  the  ordinary  cases  may  be  relieved 
by  providing  a  proper  shoe,  by  which  pressure  on  the  joint  is  com- 
pletely removed.  (Figs.  361,  378.)  The  sole  should  be  strong,  and 
it  should  be  slightly  thicker  along  the  inner  side  so  that  the  sensitive 
joint  may  be  inclined  away  from  the  upper  leather.  In  cases  in  which 
the  deformity  is  not  far  advanced,  the  use  of  a  proper  shoe  that  allows 
space  for  an  improved  position  of  the  great  toe,  combined  with  method- 
ical manual  correction  of  the  deformity,  and  exercise  of  the  disused 
muscles,  while  the  toe  is  guided  in  the  proper  directions  by  the  fingers, 
will  relieve  the  symptoms  promptly  and  practically  cure  the  deformity. 

Several  forms  of  correcting  braces  have  been  devised,  to  be  worn 
during  the  day,  a  digitated  stocking  and  special  shoe  being,  of  course, 
necessary.  But  in  the  class  of  cases  that  can  be  successfully  treated 
by  mechanical  correction,  few  patients  will  be  found  who  are  suffi- 
ciently interested  in  the  cure  of  the  deformity  to  submit  to  the  slight 
discomfort  caused  by  a  brace. 

A  simple  device  for  holding  the  toe  in  an  improved  position  is  the 
Holden  toe  post,  recommended  by  Walsham  and  Hughes.  This  is  a 
thin  piece  of  metal  so  fixed  in  the  front  and  inner  side  of  the  sole  of 
the  shoe  that  it  separates  the  first  and  second  toes  from  one  another 
and  holds  the  former  in  an  improved  position.  It  of  course  necessi- 
tates a  special  shoe  and  a  special  shoemaker  to  fit  it  in  its  proper  place. 

Operative  Treatment. — In  cases  in  which  the  deformity  is  of  long 
standing,  and  in  which  the  projecting  condyle  or  the  exostoses  make 
protection  of  the  sensitive  joint  difficult  an  operation  is  indicated.  The 
primary  object  of  the  operation  is  to  remove  the  projecting  bone.  This 
may  be  accomplished  by  a  slightly  curved  incision  about  the  inner 
aspect  of  the  condyle,  the  center  being  below  the  joint,  so  that  the  scar 
will  not  be  subjected  to  pressure.  The  flap  of  skin  is  raised,  the  peri- 
osteum and  part  of  the  capsule  are  lifted  from  the  bone,  and  the  entire 
condyle  is  removed  with  a  chisel,  so  that  the  surface  is  made  perfectly 
smooth.  Contracted  tissues  that  resist  a  corrected  position  of  the  toe 
are  stretched  or  divided,  and  the  wound  having  been  closed  with 
sutures,  a  plaster  bandage  is  applied  about  the  foot  and  toe.  This 
may  be  worn  with  advantage  for  several  weeks,  when  the  parts  will 
have  become  less  sensitive,  and  the  toe  will  have  become  accustomed 
to  an  improved  position.  The  after-treatment  is  the  same  that  has 
been  described  for  the  ordinary  cases. 


554  DISABILITIES  AND  DEFORMITIES  OF  TEE  FOOT. 

In  most  instances,  it  is  well  to  remove  the  thickened  bursa  from 
beneath  the  flap  of  skin.  As  minor  points  in  the  operation,  the  re- 
moval of  the  displaced  sesamoid  bones  has  been  advised ;  and  the 
tendency  to  recurrence  of  deformity  may  be  checked  according  to 
Weir,^  by  dividing  the  tendon  of  the  extensor  proprius  pollicis,  and 
sewing  jts  proximal  end  to  the  periosteum  of  the  inner  border  of  the 
base  of  the  first  phalanx. 

Cuneiform  osteotomy  of  the  metatarsal  bone  is  an  effective  operation 
if  the  base  of  the  Avedge  includes  the  projecting  bone.  Resection  of 
the  head  of  the  metatarsal  bone  is  as  a  rule  unnecessary,  but  it  may  be 
indicated  if  the  deformity  is  extreme. 

Hallux  valgus  is  often  combined  with  the  weak  or  broken-down 
arch ;  in  such  cases  the  foot  must  be  supported  by  a  properly  fitted 
brace.     This  is  of  especial  importance  after  treatment  by  operation. 

Bunion. — As  has  been  stated,  the  discomfort  of  hallux  valgus  is  caused 
in  great  part  by  the  irritated  bursa  and  the  over-lying  corn.  These 
symptoms  may  be  relieved  by  rest  and  by  hot  applications.  After- 
wards the  callus  or  corn  may  be  removed,  and  the  sensitive  bursa  may 
be  protected  by  a  bunion  plaster.  Operative  treatment  should  be  de- 
ferred until  after  the  acute  symptoms  have  subsided. 

Hammer  Toe. 

Hammer  toe  is  a  contraction  of  one  of  the  toes,  usually  of  the  sec- 
ond, in  which  the  first  phalanx  is  dorsi-flexed,  the  second  plantar 
flexed,  while  the  third  may  be  flexed  or  extended.  The  contracted  toe 
is  over-lapped  by  its  fellows ;  its  projecting  dorsal  surface  is  subjected 
to  the  pressure  of  the  upper  leather  of  the  shoe,  and  the  terminal  pha- 
lanx, forced  against  the  sole  of  the  shoe  and  compressed  by  the  adjoin- 
ing toes,  becomes  flattened  into  a  club  or  hammer-like  form.  The  nail 
is  distorted  and  often  "  ingrown ";  in  most  cases  a  corn  or  callus 
forms  upon  the  extremity  of  the  toe  and  a  small  bursa  and  corn  over 
the  projecting  knuckle,  on  the  dorsal  surface.  A  third  corn  or  callus  is 
often  found  beneath  the  head  of  the  metatarsal  bone  which  has  been 
forced  downward  by  the  flexion  of  the  toe. 

Hammer  toe  is  usually  bilateral ;  it  may  be  congenital,  and  heredi- 
tary even,  but  it  is  usually  acquired,  the  effect  of  shoes  that  are  too 
short  and  too  narrow.  The  second  toe  is  deformed  most  often  because 
it  is  the  longest,  and  because  it  suffers  most  from  the  lateral  compres- 
sion as  well.  The  deformity  begins,  as  a  rule,  in  early  childhood, 
when,  the  growth  of  the  foot  being  rapid,  it  is  more  likely  to  suffer 
from  the  effects  of  outgrown  shoes,  and  socks  as  well. 

Symptoms. — The  symptoms  are  practically  those  of  the  corns  or 
blisters  caused  by  the  pressure  of  the  shoe,  but  they  are  often  suffi- 
ciently troublesome  to  interfere  seriously,  not  only  with  the  comfort 
but  with  the  ability  of  the  patient. 

Treatment. — The  resistance  to  the  rectification  of  the  deformity  is 

1  Annals  of  Surgery,  April,  1897. 


DISPLACEMENT  OF  THE  FEB  ONE  I  TENDONS.  555 

caused ^,by  the  accommodative  changes  that  follow  habitual  malposition. 
In  cases  of  long  standing,  all  the  tissues  may  be  involved  in  the  con- 
traction, of  which  the  most  resistant  are  the  shortened  capsular  and 
lateral  ligaments  of  the  first  inter-phalangeal  joint. 

The  congenital  hammer  toe  of  the  infant  may  be  treated  by  manipu- 
lation. When  the  resistance  is  overcome,  the  toe  may  be  held  in  proper 
position  by  narrow  strips  of  adhesive  plaster  passed  over  and  under  it 
and  about  its  fellows.  In  older  children  a  digitation  in  the  stocking 
will  often  hold  the  toe  in  place  if  the  deformity  is  slight  and  if  a  wide 
shoe  is  worn.  In  adult  cases,  in  addition  to  the  manipulation  and  shoe, 
a  retention  apparatus,  in  the  form  of  a  light  plantar  splint,  or  stiffened 
inner  sole  to  which  the  toe  can  be  attached,  should  be  worn.  If  the 
deformity  is  more  resistant,  the  toe  may  be  straightened  by  force,  aided, 
if  necessary,  by  the  subcutaneous  division  of  the  contracted  ligaments  ; 
but  in  advanced  cases,  the  most  effective  treatment  is  resection  of  the 
joint.  Sufficient  bone  should  be  removed  to  allow  the  correction  of  the 
deformity,  or  in  case  of  its  recurrence,  to  prevent  the  projection  of 
the  joint  above  its  fellows.  By  this  operation  permanent  relief  may  be 
assured. 

Over-lapping  Toes. 

Over-lapping  toes  are  very  common  among  adults,  owing  to  the 
pressure  of  the  narrow  shoe ;  and  not  infrequently  such  deformity  is 
seen  in  infancy  and  is  apparently  congenital.  Deflected  or  deformed 
toes  may  be  treated  in  infancy  by  manipulation,  and  by  support  with 
strips  of  adhesive  plaster  in  the  manner  described.  In  childhood  ex- 
ercise and  proper  shoes  will  usually  correct  acquired  deformity.  In 
older  subjects,  an  inner  sole  somewhat  like  a  sandal,  to  which  the  toes 
may  be  attached  by  bands  of  tape,  may  be  employed  if  the  deformity 
is  considered  by  the  patient  of  sufficient  importance  to  demand  treat- 
ment. 

Exostoses  of  the  Foot. 

Simple  exostoses  of  the  foot,  as  distinct  from  those  that  are  due  to 
disease,  as  for  example,  to  rheumatoid  arthritis,  are,  in  most  instances, 
caused  by  the  pressure  upon  a  projecting  bone  of  a  somewhat  deformed 
foot.  The  common  examples  are  the  hypertrophy  of  the  scaphoid, 
often  seen  in  flat  foot  of  young  children,  the  projection  of  the  cunei- 
form bones  on  the  dorsum  of  the  hollow  or  contracted  foot,  the  enlarge- 
ment of  the  internal  condyle  of  the  first  metatarsal  bone  complicating 
hallux  valgus  and  the  exostoses  of  the  os  calcis  in  achillo-bursitis.  As 
a  rule,  the  treatment  of  the  deformity  of  the  foot  and  the  removal  of 
pressure  will  relieve  the  symptoms  without  other  treatment.  Operative 
removal  may  be  required  in  exceptional  cases. 

Displacement  of  the  Peronei  Tendons. 

Permanent  displacement  of  these  tendons  forward  of  the  malleolus, 
is  not  uncommon  as  a  result  of  paralytic  deformity,  particularly  ta- 


556 


DISABILITIES  AND  DEFORMITIES   OF  THE  FOOT. 


lipes  calcaneus,  and  in  such  instances  it  gives  rise  to  no  symptoms. 
Displacement  of  one  or  both  of  the  tendons,  or  rather  a  laxity  of  their 
attachments,  that  allows  an  occasional  displacement  or  slipping  from 
the  groove  behind  the  malleolus,  may  result  in  serious  disability,  be- 
cause of  the  pain  that  follows  the  displacement,  and  because  of  the 
Aveakness  and  insecurity  of  which  the  patient  usually  complains. 

The  cause  of  the  laxity  of  the  tissues  that  allows  displacement  in  feet 
otherwise  normal,  may  have  been  injury,  but  as  the  affection  is  often 
bilateral,  the  predisposition  may  be  congenital. 

Treatment. — If  the  displacement  is  recent,  as  when  it  follows  injury, 
the  tendons  should  be  replaced  and  the  foot  should  be  fixed  in  a  plas- 
ter bandage  until  repair  has  taken  place.  If  the  displacement  is 
habitual,  a  brace  may  be  applied  to  restrain  those  motions  at  the  ankle 
that  induce  it.  In  the  chronic  cases,  an  operation  with  the  aim  of  fix- 
ing the  tendons  by  deepening  the  groove  in  the  malleolus,  or  by  sutur- 
ing the  displaced  sheath  in  its  normal  position,  may  be  indicated.  If 
on  examination  the  cause  of  the  displacement  appears  to  be  a  shorten- 
ing of  the  tendon,  it  may  be  divided  and  lengthened  in  the  ordhiary 
manner.     (Fig.  241.) 

Shoes. 

The  shoe,  as  a  factor  in  the  etiology  of  deformity  and  disability^  has 
been  mentioned  several  times  in  the  preceding  pages,  but  it  is  a  subject 
of  such  importance  that  it  would  seem  to  call  for  special  consideration. 

The  object  of  the  shoe  is  to  cover  and  protect  the  foot,  not  to  de- 
form  it  or   to    cause  discomfort ;    therefore,  the    one    should    corre- 


FiG.  379. 


Fig.  378. 


Normal  feet. 


Proper  soles  for  normal  feet. 


spond  to  the  shape  of  the  other.  If  the  feet  are  placed  side  by 
side,  the  outline  and  the  imprint  of  the  soles  will  correspond  to  the 
accompanying  diagram.  (Fig-  378.)  The  outline  demonstrates  the 
actual  size  and  shape  of  the  apposed  feet,  emphasized  by  enclosing 


SHOES. 


557 


them  in  straight  lines.  Thus,  each  foot  appears  to  be  somewhat  trian- 
gular, b'eing  broad  at  the  front  and  narrow  at  the  heel.  The  imprint 
shows  the  area  of  bearing  surface,  and  owing  to  the  fact  that  but  a 
small  portion  of  the  arched  part  of  the  foot  rests  upon  the  ground,  it 
appears  to  be  markedly  twisted  inward.  The  sole  of  the  shoe,  if  it  is 
to  enclose  and  support  the  bearing  surface,  must  also  appear  to  be 
twisted  inward  in  an  exaggerated  right  or  left  pattern.  It  will  be 
straight  along  the  inner  border  to  follow  the  normal  line  of  the  great 
toe,  and  a  wide  outward  sweep  will  be  necessary  in  order  to  include  the 
outline  and  thus  to  avoid  compression  of  the  outer  border  of  the  foot. 
(Fig.  379.) 

This  demonstration  of  the  true  form  of  the  foot  is  almost  an  indis- 
pensable preliminary  to  an  intelligent  discussion  of  the  relative  merits 
of  shoes,  and  indeed,  it  is  somewhat  of  a  revelation  to  those  who  have 
thought  of  the  foot  only  as  it  has  been  subordinated  to  the  arbitrary 
and  conventional  standard  of  the  shoemaker.  The  ideal,  or  shoe- 
maker's foot,  upon  which  lasts  are  fashioned,  is  much  narrower  than 
the  actual  foot ;  the  great  toe  is  not  a  powerful  movable  member,  pro- 
vided with  active  muscles,  but  is  small  and  turns  outward,  so  that  the 
forefoot  is  somewhat  pyramidal  in  form  and  turns  upward  as  if  to  avoid 
the  contact  with  the  ground.  This  imaginary  foot,  drawn  after  the 
shape  of  the  ordinary  last,  appears  in  the  diagrams.  (Figs.  380,  381.) 
Upon  it  the  sole  of  the  shoe 


Fig.  380. 


Fig.  381. 


has  been  indicated,  to  con- 
trast it  with  the  shape  of 
that  necessary  to  include  the 
outline  of  the  normal  foot. 
The  actual  foot  is  thus  com- 
pressed laterally  by  the  shoe 
until  the  stretching  of  the 
leather,  during  the  "  break- 
ing in"  process,  allows  it 
to  overhang  the  sole.  The 
great  toe  is  forced  outward, 
and,  with  its  fellows,  is  com- 
pressed, distorted,  and  lifted 
off  the  ground  by  the  rocker- 
shaped  sole  (Fig.  383),  so 
that  normal  function  is  re- 
duced to  the  smallest  limit. 
Thus,  the  foot,  according 
to  the  age  at  which  the  reshaping  process  is  begun  and  the  constancy 
of  the  application,  gradually  approaches  the  ideal  and  fits  the  shoe. 
(Fig.  382.) 

This  remodelling,  however,  is  often  accompanied  by  such  discomfort 
that  the  individual  rebels  and  wears  a  shoe  with  a  square  toe,  which, 
from  the  conventional  standpoint,  is  supposed  to  show  a  meritorious 
effort  to  follow  nature.     But  the  demonstration  of  the  actual  foot  makes 


Shoemaker's  feet. 


Shoemaker's  soles. 


558 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT. 


it  evident  that  it  is  a  properly  shaped  sole,  which  serves  as  a  support, 
not  the  part  which  projects  beyond  the  foot,  that  is  of  importance.  If 
the  shoe  with  the  square  toe  is  wider,  and  straighter  on  the  inner  side 
than  another  with  a  pointed  toe,  it  is  in  so  far  an  improvement.  But, 
as  a  matter  of  fact,  one  of  the  worst  types  of  shoe  provided  for  chil- 
dren, in  shape  very  like  the  old-fashioned  coffin  lid,  owes  its  popularity 
to  the  square  toe.     The  same  comment  may  be  made  on  the  so-called 

Fig.  382. 


skiagram  of  a  foot  modeled  to  fit  the  shoe,  illustrating  the 
etiology  of  hallux  valgus. 

"  common  sense  "  shoe,  which  is  well  named,  since  it  may  be  assumed 
that  a  properly  shaped  shoe  is  an  evidence  of  uncommon  sense. 

The  object  of  the  heel  is  to  make  walking  easier  by  inclining  the 
body  somewhat  forward.  The  high  narrow  heel  is  an  insecure  sup- 
port, and  aids  deformity  by  throwing  more  strain  upon  the  forefoot 
and  pushing  it  forward  into  the  narrowest  part  of  the  shoe.  The  heel 
is  of  course  unnecessary  in  childhood,  and  should  not  be  worn,  since  it 


SHOES.  559 

limits  the  necessity  for,  and  therefore  the  use  of,  the  normal  range  of 
motion  at  the  ankle  joint.  The  ordinary  shoe,  by  restricting  the  func- 
tional use  of  the  foot,  favors  awkwardness  and  improper  attitudes.  It 
compresses  the  toes,  and  is  directly  responsible  for  corns,  bunions,  in- 
grown toenails,  and  deformities,  and  indirectly  it  causes  or  aggravates 
nearly  every  weakness  to  which  the  foot  is  liable.  This  assertion  does 
not  need  support  of  argument,  since  in  some  degree  it  has  been  proved 
by  the  personal  experience  of  every  shoe  w^earer. 

The  shape  of  the  proper  shoe  corresponding  to  the  undistorted  foot 
has  already  been  demonstrated.  (Fig.  379.)  The  sole  should  be  thick 
enough  for  protection,  but  not  so  rigid  as  to  limit  normal  motion ;  it 
should  follow  the  imprint  of  the  foot,  projecting  somewhat  beyond  the 
outline  of  the  toes ;  it  should  be  flat  (Fig.  384),  and  the  upper  leather 

Fig.  384. 
Fig.  383. 


The  rocker  sole.  The  flat  sole. 

should  be  capacious.  In  other  Avords,  the  front  of  the  shoe  should  be 
designed  to  allow  and  to  encourage  functional  activity,  the  slight  ad- 
duction of  the  great  toe  and  the  alternate  expansion  and  contraction  of 
its  fellows,  as  may  be  observed  in  the  barefoot  child.  Thus  the  arches 
may  be  supported,  and  the  weight  and  strain  properly  distributed.  The 
heel  should  be  broad  and  low.  Most  adult  feet  are  more  or  less  de- 
formed, and  therefore  better  suited  by  an  improved  than  by  a  perfect 
shoe.  Of  this  class,  what  is  known  as  the  wide  Waukenphast  pattern 
is  the  best.  In  selecting  the  better  from  the  Avorst  of  the  "  ready 
made  "  shoes,  the  breadth  of  sole,  the  angle  of  outward  deviation  of 
the  soles,  when  the  two  are  placed  side  by  side,  and  the  capacity  of  the 
upper  leather,  must  be  the  determining  points.  The  most  effective 
work  for  reform  can  be  accomplished  by  providing  proper  shoes  for 
children,  and  thus  preventing  deformity.  The  inspection  of  children's 
feet  shows  that  atrophy  and  compression  begin  at  a  very  early  age,  and 
if  protection  might  be  assured  during  the  period  of  rapid  growth, 
serious  distortion  might  be  prevented. 

Socks. — Although  of  far  less  importance  than  the  shoes,  the  socks 
worn  by  children  deserve  special  mention  as  a  factor  in  deformity, 
since  they  are  often  too  short  and  too  narrow  and  are  made  of  unyield- 
ing material,  so  that  the  proper  action  of  the  toes  is  restrained.  Theo- 
retically, the  socks,  like  the  shoes,  should  be  rights  and  lefts,  but  if 
they  are  sufficiently  large  and  of  a  texture  to  expand  readily  to  the 
shape  of  the  foot,  but  little  trouble  need  be  anticipated  on  this  score. 


CHAPTER    XXII 


DEFORMITIES   OF   THE   FOOT. 


Talipes. 

In  the  preceding  chapters,  the  disabilities  of  the  foot,  of  which  the 
symptoms  of  pain  and  discomfort  were  of  greater  importance  than 
actnal  deformity,  have  been  described.  One  now  passes  to  the  con- 
sideration of  the  congenital  and  acquired  disabilities,  of  which  deformity 
is  the  most  noticeable  feature. 

Distortions  of  the  foot  are,  practically,  fixed  positions  in  normal  atti- 
tudes, or  what  are  exaggerations  of  normal  attitudes  ;  in  other  words 
the  ordinary  deformities  can  be  voluntarily  simulated  and  the  centers 
of  motion,  at  which  the  foot  is  deformed,  are  the  centers  of  normal 

motion.     If  the  foot  has  been 
Fig.  385.  fixed  in  the  abnormal  attitude 

during  the  process  of  formation 
and  rapid  growth,  or  if  it  has 
been  used  for  any  length  of  time 
in  the  abnormal  position,  the 
deformity  becomes  exaggerated 
beyond  the  possibility  of  imita- 
tion, and  secondary  variations 
in  its  shape,  size  and  nutrition, 
follow. 

The  deformities  of  the  foot 
are  grouped  under  the  generic 
name  of  talipes,  derived  from 
talus  (ankle)  and  pes  (foot), 
signifying,  therefore,  a  form  of 
deformity  in  which  the  patient 
walks  upon  his  ankles.  Talipes 
was  thus  originally  synonym- 
ous with  the  popular  term  club 
foot,  but  at  the  present  time  it 
is  used  simply  as  a  prefix  to  the 
descriptive  titles  of  the  different 
distortions,  while  club  foot  is 
usually  applied  only  to  the  most 
common  of  the  congenital  de- 
formities, equino-varus,  in  which  the  distorted  foot  is  club-like  in  form. 
Varieties. — There  are  four  simple  varieties  of  the  distorted  foot  or 
talipes  : 


Paralytic  equinus.     Recovery  from  paralysis,  but 
deformity  persists. 


TALIPES. 


561 


1.  Talipes  equinus,  the  extended  or  plantar  flexed  foot.  In  well- 
marked  cases  the  patient  walks  upon  the  heads  of  the  metatarsal  bones, 
an  attitude  that  suggested  the  name  equinus  (horse-like). 

2.  Talipes  calcaneus,  the  dorsi-flexed  foot  in  which  the  heel  is 
prominent,  and  which  alone  bears  the  weight  in  walking ;  hence,  cal- 
caneus from  calcaneum,  the  heel  bone. 

In  these  forms  the  center  of  motion  is  at  the  ankle  joint.  Under 
the  terras  equinus  and  calcaneus,  are  included  not  only  the  cases  of 
marked  deformity,  but  also  those  in  which  the  range  of  dorsal  or  plan- 

FiG.  386. 


Congenital  calcaneus.    In  this  form  the  arch  is  obliterated, 
form  it  is  increased. 


In  the  acquired 


tar  flexion  is  sufficiently  limited  as  to  cause  a  change  in  the  contour  of 
the  foot. 

3.  Talipes  varus,  the  inverted  foot.  In  this  deformity  the  foot  is 
turned  in  or  adducted,  and  combined  with  the  inward  twist  there  is  al- 
ways a  certain  amount  of  supination,  or  inversion,  that  is,  the  inner 
border  of  the  sole  is  elevated  and  the  outer  border  is  depressed,  so  that 
the  weight  falls  to  the  outer  side  of  the  center  of  the  foot. 

4.  Talipes  valgus,  the  everted  foot.  This  deformity  is  the  reverse 
of  varus.  The  foot  is  abducted  and  pronated,  so  that,  in  use,  the 
weight  falls  on  the  inner  border. 

In  these  forms  of  lateral  deformity,  the  center  of  motion  is  at  the 
medio-tarsal  and  sub-astragaloid  joints. 
36 


562 


DEFORMITIES  OF  THE  FOOT. 


These  simple  deformities  in  which  the  foot  is  persistently  extended 
or  flexed,  or  twisted  in  or  out,  are  comparatively  uncommon. 

Compound  Deformities. — As  a  rule  the  deformities  are  combined  in 
varying  degree,  thus  the  over-extended  or  the  over-flexed  foot  is 
usually  twisted  inward  or  outward,  making  four  varieties  of  compound 
deformity. 

1.  Talipes  equixo-varus,  the  extended  and  inverted  foot. 

2.  Talipes  equixovalgus,  the  extended  and  everted  foot. 

3.  Talipes  calcAjSTeo- varus,  the  flexed  and  inverted  foot. 

4.  Talipes  calcaxeo-valgus,  the  flexed  and  everted  foot. 

In  these  more  important  deformities,  the  arch  of  the  foot  may  be  in- 
creased or  diminished  in  depth.  It  is,  for  example,  usually  increased 
in  calcaneus  and  equinus,  and  it  is  usually  diminished  in  valgus  ;  but 
this  secondary  or  subordinate  deformity  is  not  recognized  in  the  ordinary 
classification.  If  the  arch  of  the  foot  is  simply  exaggerated,  the  con- 
dition is  sometimes  called  pes  cavus  ;  if  it  is  lessened  or  lost,  it  is  called 
pes  planus.  These  slight  degrees  of  distortion,  in  which  the  func- 
tional disability  is  usually  more  important  than  the  deformity,  are 
rarely  classed  as  forms  of  talipes.  Simple  cavus,  the  hollow  or  con- 
tracted foot  ;  and  pes  planus,  one  of  the  forms  of  the  common  weak 
or  flat  foot,  have  been  described  elsewhere.     (Chapters  XXL,  XXII.) 

Etiology. — From  the  rem- 
Yia.  387.  edial  standpoint,  the  cause  of 

the  deformity  is  of  far  greater 
importance  than  its  form.  Thus 
one  divides  the  distortions  of 
the  foot  into  two  groups. 

1.  The  coxgexital  form, 
in  which  the  foot,  in  process  of 
formation,  has  slowly  grown 
into  deformity  before  birth. 

2.  The  acquired  form,  in 
which  the  foot,  perfect  at  birth, 
has  at  a  later  time  become  dis- 
torted. 

The  congenital  club  foot  may 
be  considered  simply  as  a  twist- 
ed foot,  of  which  the  component 
parts,  although  distorted  to  a 
greater  or  less  degree,  are  capable  of  regaining  perfect  form  and  function. 
This  is  practically  true  of  the  great  majority  of  cases,  although  there  are 
instances  in  which  congenital  deformity  is  complicated  by  defective  for- 
mation of  the  foot  or  leg,  or  in  which  the  deformity  is  caused  by,  or 
at  least  accompanied  by,  paralysis ;  as  for  example,  in  certain  forms  of 
spina  bifida  or  other  defect  or  disease  of  the  nervous  apparatus. 

The  acquired  deformity  is  nearly  always  a  consequence  of  paralysis 
of  spinal  origin  (anterior  poliomyelitis).  Certain  muscles,  or  groups 
of  muscles  being  paralyzed,  usually  in  early  childhood,  the  muscular 


Congenital  valgus. 


ETIOLOGY  OF  CONOENITAL    TALIPES. 


563 


force  of  the  foot  is  unbalanced  and  it  is  drawn  into  a  distorted  position 
by  the'  contraction  of  the  unopposed  muscles,  and  by  the  influence  of 
gravity.  This  distortion  is  confirmed  and  increased  by  the  accom- 
modative changes  in  the  structure  that  accompany  functional  use  and 
groAvth  in  the  abnormal  attitude. 

Far  less  often,  acquired  talipes  may  be  the  result  of  paralysis  of 
cerebral  origin,  of  other  forms  of  spinal  disease ;  of  local  paralysis  fol- 
lowing neuritis  or  injury  to  a 

nerve  trunk.   It  may  be  caused  Fie  388. 

by  scar  contraction,  as  after  a 
severe  burn,  or  by  direct  in- 
jury to  the  bone,  or  by  disease 
that  may  interfere  with  sub- 
sequent growth.  (Fig.  236. j 
Such  are,  however,  extremely 
uncommon  causes,  so  that  the 
statement  holds  good  that  the 
congenital  club  foot  is  a  simple 
distortion  capable  of  perfect 
cure.  Acquired  club  foot  on 
the  other  hand  is  a  deformity 
and  disability  usually  second- 
ary to  disease  of  the  spinal 
cord  ;  it  is  therefore  capable 
only  of  rectification  and  not  of 
perfect  cure,  unless  recovery 
from  the  original  disease,  of 
which  it  is  a  result,  has  taken 
place. 

Etiology  of  Congenital  Tali- 
pes.— As  of  other  congenital 
deformities,  the  etiology  of 
talipes  is  more  or  less  conjec- 
tural. Occasionally,  the  in- 
fluence of  inheritance  is  ap- 
parent, and  again,  two  or  more 
children  with  club  foot  may  be 
born  of  the  same  mother,  but, 
as  a  rule,  nothing  in  the  family 
or  personal  history  will  be 
found  that  may  in  any  manner  explain  the  deformity.  The  most  rea- 
sonable explanation  as  applied  to  the  majority  of  cases,  is  the  mechan- 
ical. This  is,  in  brief,  the  theory  that  the  foot  has  from  some  cause 
remained  for  a  longer  or  shorter  time  in  a  constrained  or  fixed  position, 
and  has  thus  grown  into  deformity. 

It  has  been  claimed  by  Eschricht,  and  also  by  Berg,^  that  at  about 
the  third  month  of  intra-uterine  life  the  thighs  of  the  embryo  are  ab- 
'Berg,  Archives  of  Medicine,  N.  Y.,  Dec.  1,  1882. 


Congenital  club  hands  and  feet,  combined  witli 
ancbylosis  of  nearly  all  the  joints.  (Compare  with 
Fig.  389.) 


564 


DEFORMITIES  OF  THE  FOOT. 


ducted,  flexed  and  retated  outward,  the  legs  are  crossed  and  the  feet 
are  plantar  flexed  and  adducted  so  that  the  inner  surfaces  of  the  thighs, 
the  tibial  borders  of  the  legs  and  the  plantar  surfaces  of  the  feet,  are 
held  in  close  apposition  to  the  abdomen  and  to  the  pelvis  of  the  foetus. 
Later,  there  is  an  inward  rotation  of  the  legs  so  that  the  feet  are 
turned  gradually  outward  until  the  soles  are  brought  into  contact  with 
the  uterine  wall,  the  feet  then  being  in  the  attitude  of  abduction  and 
dorsal  flexion.  According  to  this  theory,  there  is  a  regular  succession 
of  [attitudes  during  intra-uterine  life.  If  the  inward  rotation  of  the 
lower  extremity  is  prevented,  or  if  it  is  incomplete,  the  foot  remaining 

Fig.  389. 


The  etiology  of  congenital  club  bauds,  club  foot  and  anchylosis  of  the  joints.    The  habitual  attituij 
at  birth.    Photograph  at  age  of  three  months.     (See  Fig.  388.) 

in  the  original  position,  becomes  deformed.  Thus  equino-varus  being 
the  normal  attitude  of  the  early  and  middle  period  of  intra-uterine  life, 
is  not  only  the  most  common,  but  it  is  the  most  intractable  of  the  con- 
genital deformities.  But  if  the  constraint  or  pressure  is  not  exerted 
until  a  later  period,  after  rotation  has  taken  place,  when  the  foot  has 
attained  or  nearly  attained  its  normal  size  and  shape,  it  will  then  in- 
duce the  rarer  and  comparatively  slight  grades  of  deformity,  such  as 
calcaneus  or  valgus. 

This  theory,  which  seems  interesting  and  reasonable,  appearsto  rest 
on  a  very  insecure  basis.     Bessel  Hagen  states  that  in  embryos  of  30 


ETIOLOGY  OF  CONGENITAL   TALIPES. 


565 


mm.  in  length,  the  foot  is  in  extreme  plantar  flexion  ;  in  those  of  90 
to  100  mm.,  the  foot  is  at  a  right  angle  to  the  leg ;  and  from  this  size 
to  that  at  full  term,  the  foot  may  be  found  in  any  position,  abducted, 
adducted  or  dorsi-flexed.  He  states  also  that  supination  is  not  the 
usual  attitude  at  an  early  period  but  is  more  common  near  the  termi- 
nation of  intra-uterine  life,  and  when  it  is  present  it  is  more  often 
combined  with  dorsi-flexion.  In  other  words,  there  is  no  time  when 
the  foot  regularly  and  normally  assumes  the  attitude  of  club  foot,  from 
which  it  is  changed  by  the  rotation  of  the  legs.     Scudder '  after  simi- 

FiG.  390. 


latra-uterine  "  amputations."    The  patieut  is  a  tailor. 

lar  investigations,  arrived  at  practically  the  same  conclusions.  He 
states  that  there  is  no  necessary  relation  between  the  age,  the  rotation 
of  the  legs  and  the  position  of  the  feet. 

Although  the  rotation  theory  may  not  be  accepted,  still  it  would  ap- 
pear that  there  is,  during  the  process  of  development,  a  more  or  less 
regular  change  in  the  attitudes  of  the  limbs  and  feet.  If  they  are  fixed 
in  one  position  during  this  period  of  rapid  growth,  distortion  must 
follow  ;  if  the  constraint  is  slight  and  if  its  influence  is  exerted  at  a  late 
period,  the  deformity  will  be  slight ;  if  it  occurs  at  an  early  period,  the 
deformity  will  be  more  resistant. 

One  of  the  causes  of  constraint,  and  thus  of  ultimate  deformity,  ap- 
pears to  be  the  interlocking  of  the  feet.  Many  museum  specimens 
show  this,  and  in  some  of  the  cases  of  talipes  seen  during  the  first  week 
of  life,  the  feet  may  be  replaced  in  the  attitude  in  which  they  had  been 
1  Boston  Med.  and  Surg.  Jour.,  Oct.  27,  1887. 


566 


DEFORMITIES  OF  THE  FOOT. 


fixed  before  birth.  (Fig.  306.)  Intra-uterine  pressure,  although  not 
usually  the  direct  cause  of  club  foot,  undoubtedly  has  an  influence  in 
aggravating  the  deformity.  The  eifect  of  pressure  is  not  infrequently 
shown  in  atrophic  areas  of  skin ;  and  bursse  even  are  sometimes  found 
over  prominent  bones.  Entanglement  in  the  umbilical  cord,  the  direct 
pressure  of  intra-  or  extra-uterine  tumors,  and  the  like,  may  be  men- 
tioned also  as  possible  causes. 

Evidence  of  restraint  and  of  abnormal  attitudes  of  the  limbs,  is  seen 
not  infrequently  in  connection  with  club  foot ;  for  example,  in  hyper- 
extension  or  fixed  flexion  of  the  knees,  and  in  cases  of  extreme  de- 
formity, the  foot  is  often  smaller  than  normal,  and  otherwise  asymmet- 
rical. The  distorted  foot  may  be  imperfect  in  structure ;  toes  may  be 
absent,  "  spontaneous  amputation  "  (Fig.  390)  or  constricting  bands 
about  the  leg  or  foot  may  be  present.  Such  abnormalities  are  usually 
ascribed  to  amniotic  adhesions.  Talipes  may  be  combined  with  evi- 
dences of  impaired  or  arrested  development ;  with  hare  lip,  extrophy 
of  the  bladder,  spina  bifida,  and  absence  of  patellae ;  or  with  other  de- 
formities such  as  club  hand  and  wry  neck.  Or  there  may  be  evidence 
of  intra-uterine  disease,  as  in  anchylosis  of  joints  (Fig.  388)  or  so- 
called  foetal  rickets.  Finally,  deformities  of  the  foot  may  accompany 
or  are  caused  by  absence  of  bones,  as  of  those  of  the  foot ;  or  other 
deformities  and  malformations,  showing  evidently  an  abnormality  in 
the  original  make-up  of  the  germ.  This  latter  group,  which  includes 
the  complications  of  club  foot  and  imperfection  of  structure,  is  com- 
paratively small,  and,  as  has  been  already  stated,  in  the  great  majority  of 
cases,  congenital  club  foot  is  a  simple  deformity  capable  of  perfect  cure. 

Statistics. — The  most  accurate  statistics  are  those  compiled  from  the 
records  of  the  Hospital  for  Ruptured  and  Crippled  by  Townsend.^ 
These  have  been  supplemented  for  me  by  the  later  investigations  of 
Dr.  N.  B.  Waller.  In  the  combined  statistics  are  included  the  data 
of  3,453  individual  cases  of  talipes.  Of  these  1,650  were  congenital, 
and  1,803  were  acquired.  The  relative  frequency  of  the  congenital 
and  acquired  forms  of  talipes  has  given  rise  to  much  discussion  in  the 
past,  and  statistics  on  this  point  are  at  considerable  variance  with  one 
another.  This  may  be  explained  by  the  fact  that  acquired  talipes  is, 
as  a  rule,  a  preventable  deformity.  At  the  present  time,  the  extreme 
degrees  of  acquired  talipes  are  comparatively  rare,  and  the  deformity  is 
usually  of  a  much  slighter  grade  than  the  corresponding  form  of  con- 
genital distortion. 

Sex  of  Congenital  Talipes. 


Males. 

Females. 

Total. 

Townsend 

567 
498 

348 
237 

915 

Waller 

735 

'  Total 

1065 

64.5% 

585 

35.5% 

1650 

1 A  Statistical  Paper  on  Club  Foot,  Trans,  of  the  Med.  Society  of  N.  Y.,  1890. 


STATISTICS. 
Sex  of  Acquired  Talipes. 

567 

Males. 

Females. 

Total. 

460 
515 

429 
399 

889 

Waller 

914 

Total 

975 

828 
45.8% 

1803 

Percentage 

54.1% 

Congenital  talipes  is  mucli  more  common  among  males  than  among 
females.  All  statistics  are  in  accord  upon  this  point.  Acquired  talipes 
is  more  equally  divided  between  the  sexes. 


Foot  Affected  in  Congenital  Talipes. 


Eight. 

Left. 

Both. 

Total. 

274 
236 

256 
184 

385 
325 

915 

Waller 

745 

Total 

510 

30.7% 

440 

26.5% 

710 

42.7% 

1660 

Percentage  

Unilateral  950,  57.2%. 


Bilateral  710,  42.7%. 


Foot  Affected  in  Acquired  Talipes. 


Right. 

Left. 

Both. 

Total. 

Townsend 

Waller 

384 
397 

347 
421 

158 
96 

889 
914 

Total 

Pecentage 

781 
43.3% 

768 
42.6% 

254 
14.1% 

1803 

In  congenital  talipes  the  deformity  is  nearly  as  often  of  both  as  of 

one  foot,  while  in  the  acquired  form,  unilateral  deformity  is  far  more 

common.     In  each  variety  the  right  foot  appears  to  be   more  often 
affected  than  the  left. 


The  Eelative  Frequency  of  the  Different  Forms  of  Congenital 

Talipes. 


I  Townsend. 


Equino-varus 

Valgus 

Varus 

Calcaneo-valgus 

Equinus 

Calcaneus 

Equino-valgus 

Calcaneo-varus 

Cavus 

Valgo-cavus 

Equino-cavus 

Different  deformity  in  each  foot. . . 


Total. 


667 

87 

70 

15 

35 

11 

14 

4 

1 

1 

1 

9 

915 


Waller. 


605 

36 

15 

37 

5 

17 

14 

3 

4 

0 

0 

9 

745 


Total. 


1272' 
123 

85 
52 
40 

28 
28 
7 
5 
1 
1 
18 

1660 


Percentage. 


77.0 
7.4 
5.1 
3.1 
2.4 
1.7 
1.7 


568 


DEFORMITIES  OF  THE  FOOT. 


Eelative  Frequency  of  the  Different  Forms  of  Acquired  Talipes 
Together  with  the  Etiology. 


Spinal. 

Cerebral. 

Other 
forms 
of  par- 
alysis. 

Trau- 
matic. 

Total. 

Ante- 
rior po- 
liomy- 
elitis. 

Hemi- 
plegia. 

Para^ 
plegia. 

Per- 
centage. 

Equino-varus 

479 

321 

219 

134 

114 

76 

41 

12 

22 

11 

35 

1 

28 
66 
3 
4 
0 
0 
2 
0 
0 
0 

1 

1 

35 

46 

1 

7 
5 
0 
1 
0 
0 
0 
0 
0 

4 
3 
0 
1 
0 
0 
0 
0 
0 
0 
0 
0 

29 

26 

1 

27 
3 
2 
5 
0 
2 
0 
0 
0 

575 

462 

224 

173 

122 

78 

49 

12 

24 

11 

36 

2 

32.5 

Equinus 

26.1 

Calcaneus 

12.6 

Valgus 

9.7 

Equino-valgus 

6.9 

4.4 

Varus 

2.7 

Calcaneo-cavus 

Eq  uino-cavus 

1.3 

Calcaneo-varus 

Cavus 

2.0 

Varo-ca vus 

1465 

105 

95 

8 

95 

1768 

Deformity  different  on  each  side 50 

Anterior  poliomyelitis  1465,  82.8%.     Cerebral  200,  11.3%.     Traumatic  95,  5.3%. 


Comparative  Frequency  of  the  Different  Forms  of  Talipes, 
Congenital  and  Acquired. 

Congenital.  Acquired. 

Equino-varus 77  per  cent.  32.5  per  cent. 

Valgus..... 7.4  "     •'  9.7 

Varus 5.1  •'     "  2.7 

Calcaneo-valgus 3  1"     '■  4.4 

Equinus 24"      "  26.1 

Calcaneus 1.7"     "  12.6 

It  will  be  noted  that  in  three-fourths  of  the  congenital  cases  the  de- 
formity is  equino-varus,  and  that  equinus  and  calcaneus,  rare  as  con- 
genital deformities,  comprise  38  per  cent,  of  the  acquired  forms. 

Occasionally  the  deformity  is  different  on  each  foot,  far  more  often 
in  the  acquired  than  in  the  congenital  form  (50  of  the  former  or  19  per 
cent,  of  the  254  acquired  bilateral  deformities,  as  compared  with  18  or 
less  than  3  per  cent,  of  the  bilateral  congenital).  In  7  of  the  18  con- 
genital cases,  the  deformity  was  equino-varus  on  one  side,  calcaneus  on 
the  other ;  in  3  equino-varus  and  calcaneo-valgus,  and  in  3  simple 
varus  and  valgus.  The  50  cases  of  acquired  talipes  represented  every 
combination  of  deformity. 

In  31,  or  4  per  cent.,  of  the  735  cases  of  congenital  talipes  in  Wal- 
ler's table,  the  distortion  was  combined  with  other  congenital  defects 
or  deformities,  viz.:  In  12  cases  with  double  club  hands;  in  6  cases 
with  defective  development  of  the  hands,  webbed  fingers  and  the  like  ; 
in  7  cases  with  spina  bifida ;  in  3  cases  with  absence  of  one  or  more 
bones  of  the  leg  ;  in  1  case  with  torticollis ;  in  1  case  with  hare  lip ; 
in  1  case  with  dislocation  of  the  knee  and  anchylosis  of  an  elbow ;  in 
2  cases  with  general  rigidity  and  deformity  of  the  joints. 


THE  ANATOMY  OF  CONGENITAL  CLUB  FOOT. 


569 


The  Anatomy  of  Oong-enital  Club  Foot.  Talipes  Ectuino-varus. — 
CoDgeliital  talipes  is,  in  the  great  majority  of  cases,  the  form  in  which 
the  foot  is  twisted  inward  and  downward,  so  that  in  extreme  cases  it 
resembles  the  club-like  extremity  that  has  received  the  popular  name 
of  club  foot.  The  ordinary  congenital  club  foot,  in  early  infancy,  is 
simply  a  foot  held  in  an  exaggerated  attitude  of  plantar  flexion,  ad- 
duction and  supination.  The  dorsum  of  the  foot  looks  forward  and 
slightly  outward  and  upward,  the  plantar  surface  is  abnormally  con- 
cave and  looks  backward,  inward  and  downward.  The  foot  often 
seems  somewhat  smaller  than  normal  and  the  heel  appears  to  be  ill 
formed.     Upon  the  outer  dorsal  surface  the  prominence  of  the  astra- 


FiG.  391. 


Congenital  talipes  equiuo-varus  (club  foot). 

gains  and  os  calcis  may  be  felt  beneath  the  skin,  the  external  malleolus 
is  prominent,  while  the  internal  malleolus  lies  deep  beneath  the  redun- 
dant tissues  of  the  internal  aspect  of  the  foot. 

The  internal  structure  of  the  foot  is  rearranged  to  correspond  to  the 
external  contour ;  thus  the  relation  of  the  bones  to  one  another,  and 
the  shape  of  the  individual  bones  even,  are  more  or  less  altered  as  the 
deformity  is  more  or  less  of  an  exaggeration  of  the  attitudes  that  the 
normal  foot  is  capable  of  assuming.  These  changes  are  most  marked 
in  the  astragalus  and  os  calcis.  The  astragalus  is  somewhat  wedge- 
shaped  from  without  inward  ;  it  is  plantar  flexed  so  that  a  large  part  of 
its  body  protrudes  from  between  the  malleoli.     Its  neck  is  often  some- 


570 


DEFORMITIES  OF  THE  FOOT. 


what  longer  than  normal,  and  it  is,  as  a  rule,  depressed  and  deflected 
inward.  (Fig.  392,  B.)  The  os  calcis  is  also  in  an  attitude  of  plantar 
flexion  ;  the  internal  tuberosity  is  drawn  upward  to  the  vicinity  of  the 
internal  malleolus,  its  anterior  extremity  looks  downward  and  inward, 
and  it  is  often  deflected  inward  corresponding  to  the  deformity  of  the 
neck  of  the  astragalus.  Its  external  surface  looks  downward  and  for- 
Avard,  and  it  lies  directly  beneath  the  astragalus,  instead  of  to  its  outer 
side,  as  in  the  normal  relation. 

The  scaphoid  bone  is  drawn  inward  and  upward,  and  articulates  with 
the  inner  part  of  the  deflected  head  of  the  astragalus ;  it  lies  in  close 
proximity  to,  and  often  articulates  with,  the  internal  malleolus ;  the 
cuboid  is  displaced  upward  and  inward,  and  lies  to  the  inner  side  of 
the  anterior  extremity  of  the  os  calcis.  The  remaining  bones  are 
changed  in  position,  but  not  materially  in  shape.  In  many  instances 
the  tibia  is  rotated  inward  upon  the  femur,  and  this  inward  rotation  of 

the  leg  may  persist  after  the 
Fig.  392.  deformity  of  the  foot  has  been 

corrected  ;  and  in  other  cases 
there  is  often  a  moderate  de- 
gree of  knock  knee  and  laxity 
of  the  ligaments.  Less  often, 
the  tibia  is  slightly  twisted 
inward  on  its  long  axis. 

The  ligaments  are  altered 
to  correspond  to  the  changed 
relations  of  the  bones.  Those 
on  the  short  side  are  more  or 
less  resistant,  according  to  the 
duration  of  the  deformity. 
The  muscles  are  normal  as 
to  their  structure  and  their 
origin  and  insertion,  but  the 
direction  of  the  tendons  as  they  pass  across  the  foot,  is  altered  some- 
what. Those  attached  to  the  inverted  side,  the  extensor  and  adductor 
group,  are  shortened  and  are  relatively  stronger  than  those  on  the  outer 
side,  which  are  lengthened  and  atrophied  from  disuse. 

To  sum  up  :  all  the  component  parts  of  the  foot  participate  in  the 
deformity.  The  most  noticeable  changes  in  the  bones  are  in  their 
position  and  relation  to  one  another,  but  the  astragalus,  os  calcis,  and 
scaphoid  bones  are  somewhat  abnormal  in  shape  as  well. 

The  most  resistant  structures  in  the  deformed  foot  are  the  plantar 
fascia  and  the  ligaments  that  bind  the  scaphoid,  the  os  calcis  and  the 
internal  malleolus  to  one  another.  The  muscles  that  are  most  active 
in  retaining  and  increasing  the  deformity  are  the  tibialis  anticus,  the 
tibialis  posticus,  and  the  combined  gastrocnemius  and  soleus. 

The  changes  that  have  been  outlined,  which  are  comparatively  slight 
and  which  may  be  easily  rectified  soon  after  birth,  become  more 
marked  as  the  part  develops.     And  when  the  child  begins  to  walk,  the 


The  deformities  of  the  astragalus  in  club  foot  (Adams). 
A,  Astragalus  of  a  normal  infant ;  1,  from  above  ;  2,  from 
within  ;  3,  from  without.  B,  The  astralagus  in  clubfoot 
in  the  same  positions. 


THE  ANATOMY  OF  CONGENITAL   CLUB  FOOT. 


571 


weight  of  the  body,  combined  with  growth  and  functional  use  in  the 
abnorrhal  position,  increases  and  fixes  the  deformity. 

In  the  adolescent  or  adult  type  of  club  foot  that  has  remained  un- 
treated, the  deformity  is  so  extreme  that  the  patient  actually  appears 
to  walk  on  the  outside  of  his  ankles,  as  the  term  talipes  implies.  The 
feet  turn  directly  inward,  or  even  inward,  upward  and  backward,  and 
the  peculiar  walk,  by  which  interference  of  inverted  feet  is  avoided, 
has  given  another  name  (reel  foot) 
to  the  deformity. 

In  such  cases,  knock  knee  is 
usually  well  marked.  This,  al- 
though it  may  be  present  at  birth, 
is  usually  a  secondary  distortion 
caused  in  great  part  by  the  accom- 
modation to  the  deformity,  that  is, 
by  the  diminution  of  the  base  of 
support  and  by  the  interference  of 
the  feet.     (Fig.  396.) 

The  legs  are  shrunken  from  dis- 
use. Over  the  outer  border  of  the 
foot,  in  the  neighborhood  of  the  cal- 
caneo-cuboid  articulation,  there  is  a 
large  callus  with  an  underlying 
bursa.  The  foot  itself  is  atrophied 
and  is  much  smaller  than  the  nor- 
mal. The  changes  in  the  bones  are 
much  more  marked;  only  a  small 
part  of  the  articulating  surface  of 
the  astragalus  lies  between  the 
malleoli,  and  this  posterior  ex- 
tremity is  flattened  out  to  the 
shape  of  a  wedge.  There  is  con- 
sequently backward  displacement 
of  the  leg  bones,  which  is  most 
apparent  in  the  position  of  the  ex- 
ternal malleolus.  In  fact,  the 
changes  in  the  foot  may  be  so 
great  as  to  make  the  component 
parts  almost  unrecognizable.  (Figs.  391,  392,  393.)  All  the  bones  of 
the  foot  are  more  or  less  atrophied,  and  the  normal  area  of  cartilage 
has,  to  a  great  extent,  disappeared  from  the  proper  articular  surfaces. 

In  this  advanced  stage,  the  normal  muscular  activity  of  the  foot  has 
disappeared.  It  is  practically  a  simple  rigid  support,  to  which  the 
patient  has  been  so  long  accustomed  that  he  may  walk  with  compara- 
tive ease  and  with  no  discomfort,  other  than  that  caused  by  the  corns 
and  bunions  at  the  pressure  points.  In  these  extreme  cases,  cure,  in 
the  sense  of  perfect  functional  recovery,  is  of  course  out  of  the  ques- 
tion.   But  relief  of  the  deformity,  that  is,  replacement  of  the  foot  in  the 


Talipes  equino-varus  in  adolesceuce,  showing  the 
displacement  of  the  astragalus  and  its  relation  to 
the  scaphoid,  also  the  atrophy  and  distortion  of  the 
bones  of  the  leg. 


572 


DEFORMITIES  OF  THE  FOOT. 


axis  of  the  leg,  at  a  right  angle  to  it  and  in  the  plantigrade  attitude,  is 
nearly  always  possible. 

Symptoms. — The  symptoms  of  congenital  club  foot  have  been,  to 
all  intents,  included  in  the  description  of  the  deformity.  The  func- 
tional disability  is  of  course  considerable,  although  some  patients  are 
surprisingly  active  and  are  able  to  walk  long  distances.  Discomfort 
from  club  foot  is  due  almost  entirely  to  the  corns  or  inflamed  bursse 


Fig.  394. 


Fig.  395. 


Talipes   equiuo-varus. 
The  teudons  on  the  front  of  the  foot.  Showing  the  tendons  in  the  sole  of  the  foot  and 

the  extreme  displacement  of  the  os  caleis. 

over  the  bony  prominences,  and  its  degree  depends  of  course  upon  the 
use  to  which  the  foot  is  subjected. 

Treatment. — In  considering  the  treatment  of  congenital  club  foot 
it  is  customary  to  divide  it  into  several  classes  corresponding  to  the 
degree  of  resistant  deformity. 

The  first  class  would  include  the  very  slight  or  non-resistant  cases 
in  which  the  deformity  may  be  almost  entirely  corrected  by  slight 
manual  force. 

The  second  class  comprises  those  cases  in  which  a  certain  amount 
of  varus  and  well-marked  equinus  remain,  which  it  is  impossible  to 
overcome  by  manipulation. 


TREATMENT.  573 

The  first  and  second  classes  include  the  forms  of  infantile  club  foot. 

The  fhird  class  comprises  the  cases  of  more  extreme  deformity,  and 
those  in  which  the  resistance  to  the  correction  is  great,  as  in  many  of 
the  cases  in  early  childhood,  or  those  of  later  years  that  have  been  in- 
efficiently treated. 

A  fourth  class  would  include  the  untreated  cases  in  the  adolescent 
or  adult. 

Congenital  club  foot  (talipes  equino-varus)  treated  at  the  proper 
time,  that  is  to  say,  in  early  infancy,  and  in  a  proper  manner,  in  the 
great  majority  of  cases  may  be  perfectly  cured  both  as  to  form  and 
function. 

Club  foot  in  the  adult  may  be  made  straight,  but  perfect  functional 
cure  is,  of  course,  impossible. 

The  club  foot  in  childhood,  in  which  treatment  has  been  delayed,  or 
in  which  it  has  been  ineifective,  may  be  cured  as  to  form  or  function, 
but  the  eflFect  of  the  distortion  remains  in  a  certain  amount  of  atrophy 
of  the  foot  and  leg,  caused  by  the  long  disuse  of  proper  function. 

Although  congenital  club  foot  is  an  eminently  curable  deformity,  yet 
perfect  and  permanent  cure  often  requires  minute  attention  to  details 
during  the  active  stage  of  treatment,  supplemented  by  long-continued 
and  careful  supervision  after  the  cure  is  supposed  to  be  complete.  No 
other  deformity  presents  such  a  record  of  failures  and  incomplete  cures, 
of  relapses  after  apparent  cure,  of  tedious  and  ineffective  treatment  by 
braces,  often  for  many  years,  and  of  unnecessary  and  mutilating  oper- 
ations. Some  of  the  failures  may  be  explained  by  the  neglect  of  the 
parents,  or  by  want  of  opportunity.  A  few  are  due  to  the  unusual 
obstacles  in  the  deformity  itself,  but  by  far  the  greater  number  must 
be  accounted  for  by  failure  of  the  physician  to  apprehend  the  true 
nature  of  the  deformity,  or  by  his  inexperience  in  the  practical  details 
of  treatment. 

Principles  of  Treatment  of  Infantile  Club  Foot. — The  infantile  club 
foot  is,  as  has  been  stated,  simply  a  twisted  foot.  It  is  true  that  there 
are  slight  changes  in  the  bones  ;  but  the  bones  of  an  infant's  foot  are 
represented  by  yielding  cartilage,  which  will  rapidly  reform  under 
changed  conditions.  The  ligaments,  which  are  accommodated  to  the 
deformity  may  be  easily  stretched,  together  with  the  more  resistant 
muscles  and  their  tendonous  insertions,  and  when  the  proper  relation  of 
the  bones  to  one  another  has  been  restored  the  joints  will  become  normal. 

The  treatment  of  club  foot  may  then  be  divided  into  three  stages  : 

1.  The  rectification  of  the  external  deformity. 

2.  The  support  of  the  foot  in  proper  position  during  the  process 
of  transformation  of  its  internal  structure  and  until  the  normal  mus- 
cular power,  unbalanced  by  the  deformity,  has  been  regained. 

3.  The  period  of  supervision.  This  would  include  the  treatment  of 
possible  complicating  deformities  of  the  knee,  the  laxity  of  ligaments 
and  the  like,  as  well  as  the  over-sight  of  the  functional  use  of  the  foot 
and  the  leg,  during  the  early  years  of  life. 

On  examining  the  infantile  club  foot  one  will  notice  the  same  raus- 


574  DEFORMITIES  OF  THE  FOOT. 

cular  activity  that  characterizes  the  normal  foot.  Tlie  normal  infant 
moves  the  foot  in  various  directions,  in  a  more  or  less  regular  alterna- 
tion of  postures,  but  in  the  club  foot,  motion  is  in  one  direction  only, 
that  toward  which  the  foot  is  turned.  The  muscles  on  the  back  and 
inner  side  of  the  leg,  which  are  alone  active,  become  relatively  irritable 
and  hypertrophied  as  compared  with  those  on  the  front  and  outer  side, 
that  are  disused.  Thus,  muscular  activity  of  the  deformed  foot  is  in 
reality  harmful,  because  it  increases  deformity  and  still  further  disturbs 
the  muscular  balance.  For  this  reason  the  temporary  restraint  of 
motion,  necessary  during  the  rectification  of  the  deformity,  may  be 
considered  rather  of  advantage  than  otherwise.  When  movement  is 
again  allowed  and  encouraged,  it  must  be  in  the  directions  opposed  to 
the  attitudes  of  deformity,  with  the  aim  of  so  strengthening  the  weak- 
ened group  of  muscles  at  the  expense  of  the  stronger,  that  the  balance 
of  muscular  power  may  be  reestablished. 

The  First  Stage  of  Treatment — Rectification  of  Deformity. — It  should 
be  stated  at  once,  that  "  rectification  of  deformity  "  does  not  mean  ap- 
parent symmetry,  a  misapprehension  to  which  the  majority  of  failures 
in  treatment  may  be  ascribed.  It  means,  that  when  deformity  is  really 
rectified,  all  contracted  and  resistant  parts  must  have  been  so  elongated, 
that  every  passive  motion  and  attitude  possible  for  the  normal  foot,  is 
equally  possible  and  as  easily  attained  in  that  which  was  deformed. 
This  is  actual  functional  rectification,  as  opposed  to  the  simple  straight- 
ening of  deformity. 

The  most  important  part  of  the  club  foot  deformity  is  varus.  The 
foot  that  is  rolled  over  and  jtwisted  inward  to  the  attitude  of  extreme 
adduction  (Fig.  391),  must  be  untwisted  and  forced  into  an  attitude  of 
extreme  abduction  or  valgus,  the  so-called  over-correction.  (Fig.  387.) 
Until  this  is  accomplished  no  attention  whatever  need  be  paid  to  the 
residual  equinus.  There  are  two  reasons  for  dividing  the  procedure 
into  two  parts  :  First,  in  order  that  the  attention  of  the  surgeon  may 
be  concentrated  on  one  and  the  most  important  part  of  the  deformity. 
Second,  because"^ by  this  preliminary  untwisting,  the  os  calcis  is  brought 
into  the  upright  position,  into  its  proper  relation  to  the  astragalus,  to 
the  bones  of  the  leg  and  to  the  tendo  Achillis,  so  that  the  true  degree 
of  equinus  may  be  appreciated. 

Preliminary  Manipulation. — As  a  rule,  the  second  or  third  week  of 
life  is  as  early  as  mechanical  treatment  can  be  undertaken.  Until  then 
preliminary  manipulation  by  the  nurse,  more  particularly  manual  recti- 
fication of  the  deformity  by  gently  drawing  the  foot  toward  abduction 
and  retaining  it  in  the  improved  position  for  a  few  minutes,  as  often  as 
is  possible,  may  be  of  service  in  overcoming  its  resistance.  As  a  treat- 
ment by  itself,  however,  simple  manual  rectification  is  tedious  and  in- 
effective, although  partial  cures  have  been  attained  by  perseverance  in 
this  means  alone. 

Mechanical  Treatment. — Mechanical  rectification  is  the  treatment  of 
choice  and  routine  in  infantile  club  foot.  Of  this  treatment  two  methods 
may  be  described. 


MECHANICAL   TREATMENT. 


bib 


1.  By  the  plaster  bandage. 

2.  By  some  form  of  simple  splint. 

The  principle  of  the  two  is  essentially  the  same.  The  foot  is  drawn 
toward  an  improved  position  and  retained  there  by  the  plaster  bandage, 
or  it  may  be  fixed  to  some  form  of  metal  splint  or  brace  whose  shape 
is  gradually  changed  from  week  to  week,  as  the  resistance  lessens. 

Gradual  Rectification  of  Deformity  by  means  of  the  Plaster  Bandage. — 
In  this  treatment  care  should  be  taken  to  avoid  undue  pressure,  irrita- 
tion of  the  skin  or  insecurity  of  the  bandage.  One  should  place  shreds 
of  absorbent  cotton  between  the  toes ;  and  the  outer  aspect  of  the 
ankle,  where  the  skin  is  thrown  into  folds  when  the  foot  is  straight- 
ened, should  be  smeared  with 

vaseline.     A  narrow  strip  of  Fig.  396. 

adhesive  plaster  long  enough 
to  reach  from  the  knee  to  a 
point  an  inch  or  more  below 
the  heel,  is  applied  to  the 
outer  side  of  the  leg.  A  thin 
layer  of  absorbent  cotton  is 
wound  about  the  leg,  just 
below  the  knee,  in  order  to 
protect  the  skin  from  the 
hard  margin  of  the  plaster 
bandage,  and  a  similar  striji 
is  carried  about  the  toes.  The 
foot  is  then  drawn  gently 
toward  the  abducted  position, 
oiten  as  far  as  the  axis  of  the 
leg,  at  the  first  dressing, 
without  causing  discomfort. 
While  it  is  held  in  this  atti- 
tude, a  narrow  flannel  band- 
age is  smoothly  applied  to 
the  leg  and  foot,  the  band 
of  adhesive  plaster  being 
drawn  out  between  the  folds 

about  the  ankle.  A  very  light  plaster  bandage  is  then  applied, 
from  the  knee  to  the  extremities  of  the  toes,  and  into  this  bandage  the 
projecting  strip  of  adhesive  plaster  is  incorporated,  so  that  no  dis- 
placement of  the  dressing  is  possible.  The  turns  of  both  the  plaster 
and  the  flannel  bandage  are  made  from  within,  downward  and  out- 
ward, so  that  the  tension  aids  in  retaining  the  foot.  When  the  plaster 
bandage,  which  during  the  hardening  process  has  been  constantly 
rubbed  and  manipulated  so  that  it  may  fit  the  part  perfectly,  has  be- 
come firm,  a  long  stocking  is  drawn  over  it  and  is  attached  to  the  body 
clothing.  At  the  end  «f  a  week  the  bandage  is  removed.  The  leg 
and  foot  are  gently  bathed  with  alcohol,  thoroughly  dried,  powdered 
and  protected  as  before,  and  the  bandage  is  again  applied.     At  this 


Neglected  club  foot,  showiDg  the  secondary  knock  knee. 


576 


DEFORMITIES  OF  THE  FOOT. 


second  dressing,  the  irritable  adducting  muscles,  after  the  interval  of 
complete  rest,  will  be  much  less  active  and  the  contracted  tissues  will 
be  less  resistant,  so  that  the  foot  may  be  easily  turned  somewhat  out- 
ward, or  beyond  the  line  of  the  leg. 

After  four  or  five  applications  of  the  bandage,  at  weekly  intervals, 
the  foot,  in  ordinary  cases,  can  be  held  without  resistance  in  the  attitude 
of  extreme  equino-valgus.  The  sole,  which  at  first  looked  backward, 
inward  and  upward  will  be  turned  in  the  opposite  direction,  forward, 
outward  and  downward,  and  the  inner  border  of  the  foot,  which  was  con- 
cave, is  now  convex.  (Fig.  387.)  When  the  varus  has  thus  been  over- 
corrected,  treatment  is  directed  to  the  secondary  equinus.     At  this  stage 

Fm.  397. 


The  first  application  of  the  plaster  baudage,  showing  the  improved  position.    (Compare  with  Fig.  391. ) 

it  is  well  to  cover  the  bottom  of  the  foot  with  a  foot  plate  of  thin  wood 
(splint  wood  or  cigar  box  cover)  to  give  the  plaster  bandage  more  solidity, 
and  in  order  that  its  pressure  may  aid  in  fl  itenlng  the  rounded  sole. 
At  first,  one  carries  the  foot  upward  (towai  '  flot>:il  flexion)  while  it  is 
still  retained  in  the  abducted  position,  but  wIk  h  'ic  right-angled  attitude 
has  been  attained,  it  is  brought  nearer  tf>  the  axis  of  the  leg.  The 
everted  position,  or  the  attitude  opposed  to  vnru'^.  is  retained  however, 
until  correction  is  completed.  In  correcting  ihe  equinus  a  certain 
amount  offeree  is  required,  sufficient  to  crur>c  .^tme  discomfort  during 
the  application  of  the  plaster,  but  not  sufficient  to  cause  suffering  after- 
wards.    The  force  is  applied  by  means  of  the  sole  plate  to  the  entire 


MECHANICAL  TREATMENT.  577 

foot,  so  that  the  posterior  extremity  of  the  os  calcis  may  be  drawn  down- 
ward by' actual  lengthening  of  the  tendo  Achillis,  and  not,  as  is  often 
the  case,  by  an  over-correction  of  the  forefoot,  while  the  heel  remains 
in  its  original  position  of  plantar  flexion.  By  the  proper  application  of 
force  the  equinus  is  gradually  overcome ;  the  sharp  indentation  or  fold 
at  the  insertion  of  the  tendo  Achillis  is  lessened,  and  the  heel  becomes 
more  prominent. 

The  reduction  of  the  equinus  may  be  somewhat  more  difficult  than 
that  of  the  varus,  but  it  should  be  entirely  corrected  in  three  or  four 
months  from  the  time  of  beginning  the  treatment. 

As  has  been  stated,  correction  of  the  deformity  implies  over-correction. 
(Fig.  386.)  And  it  is  well,  when  this  has  been  attained,  to  hold  the  foot 
for  several  weeks,  by  means  of  the  plaster  bandage,  in  an  attitude  of 
extreme  pronation  and  dorsal  flexion  (calcaneo-valgus)  in  order  to  im- 
press, as  it  were,  the  new  position  upon  its  structure.  This  concludes 
the  first  stage  of  the  treatment,  the  simple  rectification  of  deformity. 

Correction  by  the  plaster  bandage  has  the  great  advantage  of  plac- 
ing the  treatment  entirely  under  the  command  of  the  surgeon.  Prop- 
erly applied,  the  support  is  perfectly  fitting  and  it  holds  the  foot  in  the 
desired  attitude  without  undue  pressure. 

The  disadvantages  of  the  treatment  are  almost  entirely  due  to  its 
improper  application.  For  instance,  the  bandage  may  be  too  heavy, 
or  the  padding  may  be  so  thick  that  it  does  not  retain  its  position. 
Excoriations  are  usually  due  to  carelessness  in  the  application  of  the 
bandage,  or  because  it  is  not  removed  in  proper  season.  The  fear  of 
compression,  of  atrophy  of  muscles,  of  stunting  the  growth  of  the 
limb,  is  groundless.  At  the  end  of  the  plaster  of  Paris  treatment,  the 
corrected  foot  is,  as  a  rule,  larger  than  one  that  has  remained  untreated. 
The  stunted  foot  is  the  result  of  non-treatment,  or  of  ineffective  treat- 
ment by  braces  or  otherwise ;  not  of  the  enforced  rest  necessitated  by 
the  proper  reduction  of  deformity. 

The  Rectification  of  Deformity  by  Splints  and  Braces. — Of  mechan- 
ical supports,  there  are  many  varieties.  Complicated  appliances  should  be 
avoided  because  they  are  unnecessary,  and  because  they  serve  to  distract 
attention  from  the  prime  object  of  treatment,  the  rapid  and  systematic  cor- 
rection of  deformity.  Of  the  simpler  braces,  that  used  by  Judson  is  one 
of  the  best  and  will  serve  as  a  type  to  illustrate  this. form  of  treatment. 
The  method  of  application  may  be  described  in  Judson's  own  words. 

"  The  apparatus  which  I  have  conveniently  used  to  effect  this  reduc- 
tion before  the  child  learns  to  stand,  is  a  simple  retentive  brace  which 
acts  as  a  lever  making  pressure  on  the  outer  side  of  the  foot  and  ankle, 
at  A,  in  Figs.  398  to  401,  inclusive,  and  counter-pressure  at  two 
points,  one  on  the  inner  side  of  the  leg,  at  B,  and  the  other  at  the 
inner  border  of  the  foot,  at  C.  It  is  advisable  to  keep  in  mind  that 
this  simple  instrument  is  a  lever,  because,  if  we  know  that  we  are 
using  a  lever  with  its  three  well-defined  points  of  pressure,  we  can 
make  the  apparatus  more  efficient  than  if  we  view  it,  in  a  more  general 
way,  as  an  apparatus  for  giving  a  better  shape  to  the  foot. 
37 


578 


DEFORMITIES  OF  THE  FOOT. 


"  I  use  a  little  brace  made  of  sheet  brass,  doing  the  work  with  a  few 
simple  tools.  An  advantage  of  doing  the  work  one's  self  is  that  there 
is  no  room  for  doubt  as  to  where  the  blame  lies  if  the  apparatus  does 
not  work  well.  Two  curved  disks,  B  and  C,  Figs.  400  and  401,  are 
riveted  to  a  shank,  D,  and  thus  is  formed  that  part  of  the  brace  which 
applies  the  two  points  of  counter-pressure,  while,  on  the  other  hand, 
the  point  of  pressure  is  brought  into  action  by  a  third  disk,  or  shield, 
A,  which  is  drawn  tightly  against  the  outer  side  of  the  foot  and  ankle, 
and  held  in  place  by  a  strip  of  adhesive  plaster  E,  which  includes  the 
limb  and  the  piece  which  connects  the  two  disks,  B  and  C.  The  disks 
are  lined  with  two  or  three  thicknesses  of  blanket,  easily  renewed, 
when  necessary,  with  a  needle  and  thread.     These  braces  are  so  cheap 


Fig.  398.         Fig.  399 


Fig.  400. 


Fig.  401. 


Fig.  402.       Fig.  403. 


Fig.  404. 


Fig.  405. 


The  Judson  club  foot  splint  and  its  application. 


and  easily  knocked  together  that  it  is  nothing  to  apply  new  and  larger 
ones,  using  heavier  material  for  the  shank  as  the  child  grows.  In 
general,  three  sizes  will  be  enough,  the  shanks  being  12  gauge,  |  in. 
wide;  14  gauge,  |  in.  wide;  and  16  gauge,  f  in.  wide.  The  disks 
are  conveniently  made  from  22  gauge,  1\  in.  wide.  The  rivets  are 
copper  belt-rivets.  No.  13.  A  lip  turned  on  the  edges  of  the  disks, 
with  the  flat  pliers,  gives  stiffness  to  the  thin  brass,  and  protects  the 
skin  from  the  rough  edge.  If  more  easily  obtained,  tin  disks,  light 
bars  of  iron  or  steel,  and  ordinary  iron  rivets,  would  doubtless  answer. 
"  The  brace  is  applied  with  three  strips  of  adhesive  plaster.  The 
upper  and  lower  pieces,  F  and  G,  Fig.  401,  are  simply  to  keep  the 
apparatus  in  place,  which  they  do  effectively  if  ordinary  gum  plaster 


TENOTOMY.  579 

is  used,  while,  by  drawing  the  middle  strip,  E,  tightly  over  the  shield, 
and  straightening  the  brace  from  time  to  time,  the  deformity  is  grad- 
ually and  gently  reduced.  At  each  re-application  the  brace  is  made  a 
little  straighter  than  the  foot  at  that  stage.  This  may  readily  be  done 
by  the  hands,  and  then  the  adhesive  strip  is  to  be  tightened  over  the 
shield,  till  the  shape  of  the  foot  agrees  with  that  of  the  brace.  After 
a  few  days,  the  brace  is  to  be  made  still  straighter,  and  again  re-applied, 
and  made  tight  till  another  point  of  improvement  is  gained.  The 
brace  is  applied  very  crooked  at  the  beginning  of  treatment,  as  in  Figs. 
399  and  401,  and  is  straightened  from  time  to  time,  and  a  longer 
brace  applied  as  the  deformity  is  reduced  and  the  patient  grows.  It 
should  be  removed  every  week,  or  two  weeks,  and  an  interval  of  a  few 
days  allowed  for  freedom  from  the  brace,  when  the  mother  is  advised 
to  manipulate  the  foot  constantly,  using  as  much  force  as  she  will  in 
the  direction  of  symmetry.  Manipulating  the  foot  during  these  inter- 
vals is  of  great  importance,  as  cases  have  occurred  in  which  varus  and 
equinus  have  been  entirely  overcome  by  the  mother's  hand  alone." 

"  By  this  simple  and  prosy  treatment,  carried  out  systematically  and 
without  haste,  or  violence,  or  pain,  the  foot,  unless  it  is  a  frightful  ex- 
ception, may  with  certainty  be  changed  from  varus  to  valgus.  At 
the  same  time  the  tendo  Achillis  is  lengthened  till  the  position  of  the 
foot  is  near  the  normal,  or  at  right  angles  with  the  leg,  as  the  result  of 
manipulation  and  giving  the  brace  from  time  to  time  a  partly  antero- 
posterior action.  Figs.  400  and  401  show  approximately  the  shape 
of  the  brace  at  the  beginning  of  treatment,  Figs.  402  and  403  when 
the  varus  is  reduced,  and  Figs.  404  and  405  when  valgus  has  taken 
the  place  of  varus.  The  foot,  in  this  latter  stage,  may  not  hold  itself 
valgus,  when  left  to  itself,  but  with  almost  no  force  and  with  one  finger 
it  may  be  pushed  into  valgus." 

When  the  varus  deformity  is  reduced,  the  equinus  is  gradually  cor- 
rected by  carrying  the  splint  behind  the  internal  malleolus,  and  finally, 
if  necessary,  direct  upward  pressure  may  be  applied  by  lengthening 
the  brace  and  applying  it  to  the  posterior  aspect  of  the  foot  and  leg. 
It  may  be  noted  that  manipulation  and  stretching  the  contracted  parts 
when  the  brace  is  removed,  is  of  much  importance  in  the  correction  of 
deformity  by  this  or  other  means.  Splints  of  wood,  tin,  felt  and  the 
like,  may  be  employed,  but  they  present  no  particular  advantage  over 
that  which  has  been  described. 

Tenotomy. — The  equinus  has  been  spoken  of  as  the  secondary  de- 
formity, but  its  complete  correction  is  often  more  difficult  than  that  of 
varus.  The  mechanical  stretching  of  the  contracted  parts  by  means  of 
the  plaster  of  Paris  bandage,  or  the  brace,  is  often  accomplished  with 
ease.  But  in  many  instances  time  will  be  gained,  after  the  foot  has  been 
forced  into  the  position  of  equino-valgus,  by  the  division  of  the  tendo 
Achillis,  which  is  the  most  resistant  of  the  shortened  tissues.  After 
division  of  the  tendon,  it  is  often  necessary  to  use  considerable  force  to 
stretch  the  other  contracted  parts,  and  to  force  the  foot  up  to  the  limit 
of  normal  dorsal  flexion,  which  is  the  object  of  the  operation.     Occa- 


580  DEFORMITIES  OF  THE  FOOT. 

sionally  the  obstacle  seems  to  be  in  the  posterior  ligament  of  the  ankle, 
and  it  is  sometimes  of  service  to  reinsert  the  knife  and  to  divide  this 
structure,  in  part  at  least,  so  that  it  will  give  way  under  manipulation. 
When  the  foot  has  been  forced  into  the  position  of  over-correction,  it 
is  fixed  in  a  plaster  bandage  which  is  allowed  to  remain  for  several 
weeks,  until  the  interval  between  the  separated  ends  of  the  tendon  is 
filled  in  with  the  new  tissue. 

In  many  instances,  the  leg  is  rotated  inward  upon  the  thigh,  and  the 
habitual  attitude  is  accompanied  by  accommodative  changes  in  the  liga- 
ments of  the  knee  joint.  During  the  rectification  of  the  club  foot,  this 
secondary  distortion  may  be,  in  part  at  least,  corrected  by  forcible 
manual  rotation  of  the  lower  leg  outward  several  times  daily. 

Recapitulation. — The  management  of  the  first  stage  of  the  treatment 
of  infantile  club  foot  is  then — manipulation  of  the  foot  by  the  nurse 
from  birth  until  systematic  rectification  can  be  begun — mechanical 
correction,  first  of  the  varus  and  then  of  the  equinus  deformity,  termi- 
nating with  a  period  of  retention  in  the  over-corrected  position  (cal- 
caneo-valgus).  Division  of  tendons,  other  than  the  tendo  Achillis,  is 
not  often  necessary.  The  time  required  for  the  completion  of  the  first 
stage  of  treatment,  or  over-correction  of  deformity,  should  not,  under 
favorable  conditions,  exceed  three  months. 

The  rapid  correction  of  deformity  in  the  manner  described,  begun 
as  early  as  possible  and  accomplished  as  quickly  as  possible,  cannot  be 
too  strongly  urged.  In  the  first  months  of  life  the  tissues  are  not  re- 
sistant, the  bones  are  practically  entirely  cartilaginous,  and  when  the 
foot  in  its  external  appearance  is  rectified,  the  rapid  growth  in  the 
first  months  of  life  will  change  the  internal  structure  to  conform  to  the 
normal  conditions.  The  fear  of  atrophy,  compression  or  other  harm 
from  the  temporary  fixation,  necessary  during  rectification,  is  ground- 
less, and  in  fact,  exercise  so-called,  except  in  the  direction  opposed  to 
deformity,  is  harmful  rather  than  beneficial. 

Correction  of  deformity  may  be  accomplished  by  holding  the  foot  in 
an  improved  position  by  strips  of  adhesive  plaster,  or  by  the  elastic 
traction  of  rubber  bands,  attached  to  the  leg  and  foot.  As  compared 
with  the  ease,  rapidity,  and  certainty  of  correction  by  means  of  the 
plaster  bandage,  such  methods  are  uncertain  and  ineffective  and  they 
will  not  therefore  be  described  in  detail. 

The  Second  Stage  of  Treatment.  Support  and  Restoration  of  Function. 
When  the  deformed  foot  has  been  corrected,  in  the  sense  that  all 
normal  motions  can  be  carried  out  by  passive  force,  the  first  and  most 
difficult  part  of  the  treatment  will  have  been  completed,  and,  in  some 
instances,  the  deformity  is  actually  cured.  Such  a  result  is  unusual 
however,  for  although  the  foot  may  be  normal  in  appearance,  its  mus- 
cular balance  has  not  been  restored.  This  is  shown  by  the  fact  that 
when  support  is  removed,  the  foot  usually  hangs  downward  and  inward, 
and  there  is  little  apparent  power  in  the  dorsi-flexors  and  abductors  to 
draw  it  upward  and  outward.  If  at  this  stage  treatment  were  aban- 
doned, the  deformity  would  almost  invariably  recur,  at   least  in  part. 


THE  RETENTION  BRACE. 


581 


For  thi^  reason,  the  foot  must  be  supported  iu  proper  position  until 
the  slack  of  the  lengthened  tissues  has  been  taken  up  by  development 
in  the  normal  attitude,  aided  by  massage  and  stimulation  of  the  mus- 
cles. Practically,  support  is  always  necessary  until  the  child  has  be- 
gun to  walk. 

The  Eetention  Brace. — The  form  of  retention  brace  will  vary 
somewhat  according  to  the  indications  of  the  individual  case.  The 
best  and  simplest  support  is  the  Taylor  brace,  the  invention  of  Dr. 
C.  F.  Taylor,  of  New  York.  (Fig.  406.)  This  consists  essentially 
of  a  light  upright  that  extends  along  the  inner  side  of  the  leg  to  the 
knee,  and  a  thin  steel  foot  plate  of  the  exact  size  of  the  sole,  with  an 

Fig.  406. 


The  Taylor  club  foot  brace. 

upright  flange  on  the  inner  side,  rising  to  a  point  just  above  the  dorsal 
surface  of  the  foot,  against  which  the  foot  is  pressed  closely  so  that 
recurrence  of  the  varus  deformity  is  prevented.  The  joint  at  the 
ankle  is  provided  with  a  catch  that  prevents  plantar  flexion,  but  al- 
lows dorsi-flexion.  By  bending  the  upright  and  the  sole  plate,  the 
foot  may  be  held  in  slight  abduction  and  e version.  The  apparatus 
is  applied  with  straps,  as  illustrated,  and  if  necessary,  its  position 
is  further  fixed  by  a  band  of  adhesive  plaster,  applied  on  the  inner 
side  of  the  leg  to  hold  the  heel  firmly  against  the  foot  plate.  The 
foot  is  thus  held  constantly  at  a  right  angle  to  the  leg,  or  better  in 
the  early  stage  of  treatment,  in  an  attitude  of  dorsi-flexion  and  val- 
gus.    Occasionally,  after  complete  rectification  of  the  deformity,  the 


582 


DEFORMITIES  OF  THE  FOOT. 


foot  still  turns  in.     In  most  instances,  this  is  due  to  an  inward  rotation 
of  the  tibia  on  the  femur  at  the  knee  joint,  but  in  some  cases,  it  is 


Fig.  407. 


Fig.  408. 


Taylor  club  foot  brace  showing  the  method  of  application  and  attachment. 

caused  by  a  spiral  twist  of  the  tibia  itself.     In  order  to  correct  this 
secondary  deformity,  an  extension  of  the  upright  of  the  brace  is  carried 


Fig.  409. 


Fig.  410. 


The  Taylor  club  foot  brace  showing  the  adhesive  plaster,  by  means  of  which  the  heel  is  helddown, 
and  the  method  of  attachment.  This  brace  may  be  used  to  correct  deformity  as  well  as  to  retain  the 
foot  in  proper  position,  as  is  illustrated  by  these  figures.  As  a  retention  apparatus  the  foot  plate 
should  be  held  at  a  right  angle  to  the  upright  by  tlie  stop  joint  shown  in  Fig.  400. 


METHODICAL  MANUAL   CORRECTION.  583 

beneath^ the  leg,  provided  with  a  joint  at  the  knee  and  is  extended  up 
the  outer  side  of  the  thigh.  At  the  hip  it  is  attached  by  a  free  joint 
to  a  padded  pelvic  band  of  light  steel.  (Fig.  415.)  The  band  holds 
the  upright  in  the  proper  relation  to  the  thigh,  thus,  by  twisting  the 
part  below  the  knee,  the  foot  can  be  rotated  outward  to  the  desired 
degree.  In  less  marked  cases  the  retention  bands  used  for  pigeon  toe 
may  be  employed.     (Fig.  377.) 

Methodical  Manual  Coeeection. — Several  times  during  the 
day  the  brace  should  be  removed  in  order  that  the  foot  may  be  thor- 
oughly massaged  and  forcibly  turned,  first  toward  valgus,  that  is,  out- 
ward at  the  medio-tarsal  joint  so  that  the  inner  border  is  made  con- 
vex, and  then  to  the  extreme  limit  of  dorsi-flexion  and  abduction.  If 
the  leg  is  rotated  inward,  it  is  forcibly  rotated  outward  on  the  femur. 
Even  if  the  tibia  is  actually  twisted  on  its  long  axis,  the  influence  of 
the  brace  and  forcible  manipulation  will  usually  correct  the  deformity. 
Active  contraction  of  the  weak  muscles  may  be  induced  by  tickling  the 
sole  of  the  foot  or  by  the  use  of  electricity  ;  and  finally,  the  entire 
limb  should  be  thoroughly  massaged  before  the  brace  is  reapplied. 

When  the  deformity  shows  no  tendency  to  recur,  the  brace  may  be 
removed  for  a  part  of  the  day,  later  it  is  used  only  at  night,  and  finally 
it  may  be  discarded  if  the  child  walks  normally.  But  it  is  best  to 
continue  the  daily  manipulation,  more  particularly  the  systematic 
stretching  or  over-correction  of  the  foot,  for  a  long  time.  Thus  one 
may  assure  oneself  that  there  is  no  tendency  toward  deformity,  of 
which  the  first  symptom  is  always  a  slight  limitation  of  the  range  of 
dorsal  flexion  and  of  abduction. 

In  many  instances,  the  deformity  may  have  been  so  thoroughly  over- 
corrected  by  the  plaster  of  Paris  bandage  or  by  the  brace,  and  the 
after-treatment  of  massage  and  stretching  may  have  been  so  efficiently 
applied  by  the  nurse  or  parent,  that  the  retention  brace  may  be  unneces- 
sary. On  the  other  hand,  the  inclination  toward  deformity  may  be  so 
marked  that  a  brace  may  be  necessary  to  hold  the  foot  in  slight  abduc- 
tion and  valgus  for  a  year  or  longer.  In  other  cases,  the  use  of  a 
light  brace  to  hold  the  foot  in  the  over-corrected  position  during  the 
night  is  alone  required.  These  are  points  to  be  decided  by  the  cir- 
cumstances in  each  case.  The  period  of  observation  and  supervision 
is  included  in  the  final  stage  of  the  treatment. 

Third  Stage  of  Treatment — Supervision. — During  this  period,  the  at- 
titudes of  the  limb  and  foot  of  the  walking  child  must  be  carefully 
watched,  and  particularly  the  signs  of  wear  on  the  sole  of  the  shoe. 
If  it  shows  greater  wear  on  the  outer  side  than  is  usual,  it  is  an  indi- 
cation that  the  weight  does  not  fall  directly  on  the  center  of.  the  foot 
but  to  the  outer  side,  and  that  there  is  therefore  a  tendency  toward  de- 
formity. This  must  be  counteracted  by  making  the  sole  thicker  on 
the  outer  side  or  slightly  wedge-shaped,  so  that  the  weight  may  be  de- 
flected toward  the  inner  border. 

This  third  period  of  treatment,  or  rather  of  over-sight  of  the  func- 
tional use  of  the  foot,  must  be  continued  indefinitely.     In  fact,  it  is 


584  DEFORMITIES  OF  THE  FOOT. 

the  quality  of  this  final  supervision  that  decides  in  most  instances 
whether  the  ultimate  outcome  is  to  be  what  is  called  a  satisfactory  re- 
sult, or  a  perfect  cure. 

The  Treatment  of  Neglected  Club  Foot. 

The  treatment  of  club  foot,  under  what  may  be  called  the  proper 
conditions,  as  outlined  in  the  preceding  pages,  applies  practically  to  all 
cases  before  the  completion  of  the  first  year  of  life,  and  mechanical 
rectification  may  be  successfully  employed  in  cases  far  beyond  this 
limit  of  age.  As  a  rule,  however,  when  the  patient  has  walked  for 
any  length  of  time,  the  resistance  of  the  tissues  has  increased  to  such 
an  extent,  that  more  rapid  and  effective  treatment  is  indicated.  The 
investigations  of  Wolff  have  shown  that  the  internal  structure  of  the 
bones  corresponds  to  their  external  contour,  and  that  the  structure  and 
contour  are  adaptations  to  functional  use.  This  internal  structure  is 
not,  however,  permanent,  but  is  readily  transformed  to  conform  to 
changes  in  form  or  function.  If  then,  the  external  contour  of  the 
club  foot  were  suddenly  reversed,  and  if  use  of  the  foot  were  per- 
mitted in  this  new  attitude,  a  transformation  of  the  internal  structure 
of  the  bones  and  at  the  same  time  of  their  shape,  would  begin  at 
once.  This  would  continue  until  both  structure  and  shape  had  become 
adapted  to  habitual  function.  It  is  upon  this  natural  power  of  trans- 
formation that  one  depends  for  the  final  and  complete  change  of 
the  distorted  bones  to  the  normal ;  and  what  is  true  of  a  resistant 
structure,  like  bone,  is  equally  true  of  the  other  constituents  of  the 
deformed  foot. 

Age  as  Influencing  Treatment. — There  is  then  this  very  es- 
sential difference  between  the  indications  for  treatment  in  infancy  and 
in  childhood.  In  the  first  instance,  the  foot  has  no  essential  function. 
In  the  walking  child,  however,  the  weight  of  the  body  and  habitual 
use  tend  to  confirm  and  to  increase  the  deformity.  If  walking  is  al- 
lowed during  the  process  of  rectification  of  the  foot,  it  must  necessarily 
retard  its  progress.  As  a  general  principle  of  treatment,  walking 
should  not  be  permitted,  until  the  weight  of  the  body  may  aid  rather 
than  retard  the  correction  of  deformity.  The  great  numbers  of  compli- 
cated and  cumbersome  machines  that  have  been  used  in  the  treatment  of 
club  foot  were  designed  to  correct  gradually  the  deformity  in  walking 
children.  But  however  efficacious  one  or  another  of  these  may  have 
been  in  the  hands  of  its  inventor,  or  of  one  skilled  in  its  use,  such  forms 
of  apparatus  applied  under  ordinary  conditions,  simply  serve  to  delay 
effective  treatment  and  to  fix  rather  than  to  correct  the  deformity. 
The  most  important  function  of  the  brace,  aside  from  its  use  as  a 
correcting  appliance  in  early  infancy,  is  to  support  the  foot  after  de- 
formity has  been  corrected,  and  to  guide  it  in  its  functional  use  until 
its  normal  strength  has  been  regained.  And  although  it  may  be  ad- 
mitted that  rectification  of  deformity,  even  in  adolescence,  by  simple 
mechanical  means  alone  is  perfectly  possible,  yet,  only  in  exceptional 


FORCIBLE  MANUAL  CORRECTION. 


585 


cases  \^ould  one  be  justified  in  selecting  a  treatment  so  tedious,  which 
offers  practically  no  advantage  over  more  rapid  methods. 

The  Rapid  Correction  of  Deformity. — The  principles  on  which  opera- 
tive treatment  is  conducted  are  the  same  that  govern  mechanical  treat- 
ment. Thus,  the  deformed  foot  must  be  over-corrected,  and  it  must 
be  held  in  the  over-corrected  position,  until  the  immediate  tendency 
toward  deformity  has  been  overcome.  It  must  then  be  supported,  until 
the  process  of  transformation  of  its  internal  structure  is  completed, 
and  until  the  balance  of  muscular  power  has  been  regained.  This 
general  rule  of  treatment  is  entirely  opposed  to  the  supposition  that  a 
surgical  operation,  no  matter  how  radical,  can  be,  in  childhood  at  least, 
curative  by  itself  alone.     Operative  procedures  are  undertaken  simply 


Fig.  411. 


Reduction  of  the  varus  deformity.     (Lokenz.  ) 

for  the  purpose  of  making  the  primary  over-correction  possible ;  and 
that  operation  by  which  this  object  can  be  accomplished,  with  the  least 
interference  with  the  structure  of  the  foot,  should  be  selected.  Such 
an  operation  is  what  may  be  called  forcible  manual  correction. 

Forcible  Manual  Correction. — The  patient  having  been  anaesthetized, 
one  first  attempts  to  correct  the  sharp  inward  twist  at  the  medio-tarsal 
joint.  Supposing  the  left  foot  to  be  deformed,  one  grasps  the  heel 
with  the  right  hand,  in  such  a  manner  that  the  projection  or  muscular 
part  of  the  palm  lies  on  the  outer  aspect  of  the  foot,  against  the  most 
prominent  part  of  its  outer  border,  which  is  at  the  junction  of  the  os 
calcis  and  cuboid  bones.  This  hand  serves  as  a  fulcrum,  over  which 
the  inverted  foot  may  be  bent.     The  forefoot  is  then  grasped  firmly 


586 


DEFORMITIES  OF  THE  FOOT. 


by  the  left  hand  and  one  begins  a  series  of  outward  twists  over  the 
fulcrum  of  the  opposing  palm,  gently  at  first  with  alternate  relaxation 
of  pressure,  but  with  gradually  increasing  force  as  the  resistant  tissues 
stretch  under  the  tension. 

If  greater  force  is  required,  a  triangular  block  of  wood,  well  padded, 
may  be  used  as  the  fulcrum  (Fig.  411),  one  hand  pressing  on  the 
heel  and  the  other  on  the  forefoot,  but  there  is  a  great  advantage  in 
using  nothing  but  the  hands,  because  one  feels  sure  that  no  injurious 
force  is  likely  to  be  exerted.  Under  this  steady  manipulation  the  foot 
soon  loses  its  rigidity  and  its  elastic  recoil  toward  deformity — it  becomes 


Fig.  412. 


1  latttuiug  the  sole.      (Lokenz.) 

so  limp  that  with  two  fingers  one  can  not  only  hold  the  sole  straight,  but 
can  push  it  or  bend  it  outwards.  Thus  the  first  stage  of  the  method- 
ical correction  has  been  accomplished. 

One  then  turns  his  attention  to  the  supination  which  makes  the  outer 
border  of  the  foot  lower  than  the  inner  border.  The  leg  is  grasped 
firmly  near  the  ankle  with  the  left  hand  and  with  the  right  the  foot  is 
forcibly  twisted  in  a  direction  downward,  outward  and  ujiward,  over 
and  over  again,  with  steadily  increasing  force  as  the  tissues  slowly  yield, 
until  it  may  be  forced  into  a  position  of  extreme  abduction,  so  that 
the  sole  may  be  made  to  look  outwards  and  downwards — the  reverse  of 
the  former  attitude. 


FORCIBLE  MANUAL   CORRECTION. 


587 


One  next  stretches  the  contracted  plantar  fascia  and  reduces  the  cavus 
which  is  usually  present,  by  forcing  the  forefoot  toward  dorsiflexion, 
against  the  resistance  of  the  contracted  tendo  Achillis,  until  the  sole  is 
made  perfectly  flat.  (Fig.  412.)  Finally,  the  fourth,  and  often  the  most 
difficult  part  of  the  rectification,  that  of  forcing  the  displaced  astragalus 
into  its  proper  position  between  the  malleoli,  is  attempted.  To  ac- 
complish this,  the  tendo  Achillis  is  first  divided  subcutaneously,  and  if 
necessary  the  posterior  ligament  of  the  ankle  is  also  divided  at  the  same 
time.  The  patient  is  then  turned  upon  his  face  so  that  with  the  knee 
resting  on  the  table  the  leg  is  held  upright.  This  allows  one  to  hook 
the  fingers  about  the  extremity  of  the  os  calcis  while  the  hand  and  arm, 
lying  along  the  sole  of  the 

foot,  may   be   used  as  a  Fig.  413. 

lever  to  force  it  toward 
dorsal  flexion  as  the  os 
calcis  is  drawn  down- 
ward. In  this  manner 
forcible  stretching  is  con- 
tinued until  the  dorsum 
of  the  foot  can  be  brought 
almost  into  apposition 
with  the  crest  of  the  tibia. 
When  the  operation  has 
been  completed,  the  foot 
should  be  perfectly  limp. 
It  is  usually  somewhat 
congested  from  the  pres- 
sure of  the  fingers,  but 
it  is  warm  and  the  circu- 
lation is  unimpaired. 

One  may  assume  that 
in  the  change  that  has 
taken  place  from  rigid 
deformity  to  a  limp  foot 
that  can  be  moulded  into 
the  desired  shape,  the 
component  parts  of  the 
deformed  foot  must  have  been  subjected  to  considerable  violence  ;  that 
ligaments  and  muscles  must  have  been  stretched,  and,  it  may  be,  rup- 
tured ;  that  new  surfaces  are  now  opposed  to  one  another  in  the  articu- 
lations, and  that  the  bones  have  been  forced  into  approximately  normal 
position.  This  method  of  treatment  has  a  great  advantage  over  the 
ordinary  operative  treatment,  in  that  the  entire  foot  participates  in  the 
correction,  instead  of  a  limited  portion,  as  when,  for  example,  bone  is 
removed  by  cuneiform  osteotomy.  It  has  a  second  and  almost  equally 
important  advantage,  in  that  the  immediate  use  of  the  corrected  and 
yielding  foot  is  possible  in  the  place  of  the  necessary  rest  that  must 
follow  cutting  operations.     For  these  reasons  forcible  massage  should 


Reduction  of  the  equinus  deformity.    (Lorenz.) 


588 


DEFORMITIES  OF  THE  FOOT. 


Fig.  414. 


be  the  operation  of  choice,  and  preliminary,  at  least,  to  more  severe 
procedures  in  the  treatment  of  resistant  club  foot  in  childhood.  The 
only  disadvantage  of  the  operation  is  the  actual  labor  which  it  necessi- 
tates on  the  part  of  the  surgeon,  usually  twenty  minutes  or  more  of 
rather  exhausting  work. 

The  foot  must  now  be  fixed  by  a  plaster  bandage  in  an  over-corrected 
position.  It  is  first  evenly  covered  with  a  layer  of  cotton,  and  a  broad 
bandage  of  canton  flannel  and  while  it  is  held  by  the  assistant,  the 
plaster  bandages  are  applied  from  the  tips  of  the  toes  to  the  upper 
part  of  the  thigh.  It  is  important  that  the  toes  should  not  project 
beyond  the  bandage,  because  of  the  swelling  that  sometimes  follows. 

It  is  important,  also,  that  the  foot 
should  be  held  in  the  proper  posi- 
tion while  the  bandage  is  harden- 
ing, and  that  it  should  not  be  manip- 
ulated to  any  extent  after  the  band- 
age is  applied,  in  order  that  no  rigid 
wrinkle  may  press  against  the  skin. 
The  bandage  is  applied  above  the 
knee  in  order  that  the  tibia  may 
be  rotated  outward  to  its  normal 
position  and  held  there,  and  because 
more  effective  fixation  may  be  as- 
sured and  greater  pressure  exerted 
on  the  foot  in  walking.  To  utilize 
this  pressure  to  better  advantage 
the  bandage  should  be  made  very 
thick  beneath  the  sole,  and  a  thin 
foot  plate  of  wood  should  be  incor- 
porated in  the  plaster.  When  the 
bandage  is  applied  the  position  of 
the  foot  should  be  that  of  over-cor- 
rection of  deformity,  flexed  beyond 
the  right  angle,  twisted  far  outward, 
and  the  outer  border  should  be  elevated  considerably  beyond  the  level 
of  the  inner  border.     (Fig.  414.) 

One  would  suppose,  after  using  the  force  that  has  been  necessarily 
applied,  that  much  pain  and  swelling  would  follow.  This  is,  however, 
not  the  case.  Often,  on  the  following  day,  the  patients  are  able  to 
stand  upon  the  foot,  and  always  within  the  first  week  if  the  bandage 
has  been  properly  applied.  The  pain  following  this  operation  is  far 
more  often  caused  by  pressure  of  an  ill-fitting  bandage  than  by  the 
violence  that  has  been  used.  Thus  one  should  be  careful  to  remove 
sections  of  the  bandage  if  it  appears  to  cause  undue  discomfort.  These 
points  are  usually  the  front  of  the  ankle,  the  back  of  the  heel  and  the 
inner  border  of  the  great  toe. 

The  Importance  of  Functional  Use. — The  immediate  use  of 
the  foot  is  encouraged,  in  order  that  the  weight  of  the  body  falling  on 


The  attitude  of  over-correction  in 
which  the  feet  are  fixed  after  the  opera- 
tive treatment. 


THE  IMPORTANCE  OF  FUNCTIONAL    USE.  589 

the  yielding  structure  may  still  further  correct  the  deformity.  Although 
only  the  heel  and  inner  border  bear  weight  directly,  yet  the  pressure  of 
the  foot  plate  on  the  parts  that  do  not  come  in  contact  with  the  floor  is 
usually  sufficient  to  mould  the  foot  into  its  proper  shape.  If  greater 
pressure  is  thought  to  be  necessary,  wedges  of  wood  or  cork  may  be 
attached  to  the  sole  of  the  plaster  bandage  so  that  all  parts  may  bear 
weight  equally.  The  bandage  is  covered  by  a  stocking ;  a  slipper  may 
be  worn  indoors  and  an  ordinary  over-shoe  for  street  wear. 

The  first  bandage  should  be  removed  at  the  end  of  about  three  weeks 
as  it  will  have  become  loose.  The  foot  will  then  be  found  to  be  ex- 
tremely flexible,  and  by  an  enthusiast  it  might  be  considered  cured.  But 
knowledge  of  its  previous  condition  should  make  it  evident  that  a  much 
longer  time  will  be  necessary  to  allow  for  its  consolidation  in  the  new 
position.  At  this  time  almost  no  evidence  of  the  operation  remains,  ex- 
cept, it  may  be,  slight  discoloration  of  the  skin.  The  foot  is  again  held 
as  far  as  possible  in  the  over-corrected  position  and  another  plaster 
bandage  is  applied,  usually  as  far  as  the  knee  only.  This  remains  for 
four  weeks,  or  longer  if  it  is  still  unbroken.  The  patient  uses  the 
foot  constantly,  and  is  drilled  in  the  proper  method  of  walking,  so  that 
the  muscles  of  the  leg  may  become  accustomed  to  the  new  and  normal 
attitudes. 

At  the  end  of  another  month  or  more,  the  plaster  is  replaced  by  a 
brace  to  be  worn  inside  the  shoe,  usually  of  the  simplest  description, 
consisting  of  an  upright  bar  with  a  calf-band,  attached  to  a  steel  sole- 
plate  by  a  joint  that  will  allow  dorsal  flexion  but  checks  extension  at 
a  right  angle.  This  is  applied  because  the  dorsal  flexors,  after  years 
of  disuse,  only  slowly  recover  sufficient  power  to  resist  the  action  of 
the  opposing  group  and  the  force  of  gravity. 

The  second  stage  of  the  treatment  is  now  begun.  This  may  be  di- 
vided into  a  period  of  active  treatment  and  one  of  supervision.  The 
first,  or  treatment  stage,  consists  in  massage  of  the  entire  leg  and  of 
the  foot  to  stimulate  the  growth  of  the  atrophied  muscles,  and  method- 
ical manipulation  of  the  foot  several  times  a  day.  The  important 
point  in  this  manipulation  is  to  force  the  foot  with  the  hand  to 
the  extreme  of  the  range  of  motions  possible  immediately  after  the 
operation,  viz.,  eversion,  abduction  and  dorsal  flexion,  in  the  same 
order,  as  at  the  time  of  operation.  At  the  same  time  the  patient 
attempts  voluntarily  to  carry  out  these  motions  by  his  own  muscles, 
the  power  being  supplied  by  the  hand  of  the  masseur.  Slowly  the 
muscles  gain  in  strength  and  ability  and  when  normal  muscular  power 
and  balance  have  been  regained  the  patient  is  practically  cured.  But 
for  long  afterward  supervision  is  kept  up,  of  the  patient's  attitude,  of 
the  manner  of  using  the  foot,  of  the  wear  of  the  sole  of  the  shoe,  and 
the  like ;  and  by  constant  drilling  and  stimulation  the  attempt  is  made 
to  restore  the  normal  appearance  and  function. 

One  cannot  exaggerate  the  importance  of  this  after-treatment,  and  of 
supervision  at  least,  on  the  part  of  the  surgeon.  The  active  treatment 
may  often  be  left  to  the  parents.     But  constant  supervision  is  neces- 


690 


DEFORMITIES  OF  THE  FOOT. 


Fig.  415. 


sary  to  keep  this  after-treatment,  which  seems  so  common-place  and  sim- 
ple, up  to  the  proper  pitch  ;  to  assure  oneself  that  the  range  of  motion 
regained  by  the  operation  does  not  gradually  become  more  and  more 
restricted,  even  though  the  contour  of  the  foot  appears  to  be  normal. 

Forcible  manual  correction  may  be  employed  with  advantage  from 
the  second  to  the  tenth  year,  although  the  limits  may  be  extended  in 
either  direction  in  special  cases.     In  this  operation,  as  described,  the 

tendo  Achillis  is  the  only  structure  di- 
vided. There  is  no  particular  objection 
to  subcutaneous  division  of  other  ten- 
dons or  ligaments  in  connection  with 
forcible  manual  correction.  But  in  such 
prolonged  manipulation  it  is  much  bet- 
ter if  the  skin,  which  itself  must  be 
stretched,  is  unbroken  and  dry,  rather 
than  moist  from  the  bleeding  from  punc- 
tured wounds.  For  this  reason  it  is 
well  to  correct  the  deformity  without 
extensive  tenotomy  if  possible.^ 

Secondary  Deformities. — In  cases  such 
as  have  been  described,  a  certain  amount 
of  secondary  deformity  of  the  leg  is  often 
present.  Knock  knee  rarely  requires 
other  treatment  than  daily  manual  cor- 
rection, in  connection  with  the  massage 
of  the  foot  and  leg.  Hyper-extension 
at  the  knee  will  correct  itself  during  the 
treatment  of  the  foot,  which  being  fixed 
in  an  attitude  of  dorsal  flexion  obliges 
the  patient  to  bend  the  knee  habitually 
in  walking.  Inward  rotation  of  the  leg 
upon  the  thigh  is  often  present.  This 
may  be  overcome  by  methodical  ma- 
nipulation and  by  the  use  of  a  brace 
that  is  attached  to  a  pelvic  band. 
(Fig.  415.) 

In  many  instances,  particularly  in 
childhood  and  adolescence,  the  patient 
has  so  long  walked  with  exaggerated 
outward  rotation  of  the  femur,  that  after  correction  of  the  deformity  no 
inward  rotation  of  the  foot  appears,  even  though  inward  rotation  of  the 
tibia  be  present.  In  other  cases  the  inward  rotation  of  the  foot  is 
caused  by  a  failure  to  completely  replace  the  astragalus  between  the 


The  Taylor  club  foot  brace  with 
pelvic  band,  to  prevent  rotation  of  the 
leg.  The  brace  is  shovrn  before  the 
covering  and  straps  are  applied. 


'  Forcible  manual  correction  appears  to  have  been  described  first  by  Delore.  Lorenz 
employs  the  method  in  connection  with  his  osteoclast  to  the  exclusion,  practically, 
of  all  other  treatment.  (Heilung  des  Klumpfusses  darch  das  modellirende  Redresse- 
ment,  Wiener  Klinik,  Nov.,  1895. )  The  modification  of  the  treatment  that  has  been 
described  has  been  employed  by  the  author  for  many  years. 


SUBCUTANEOUS  TENOTOMY.  591 

malleoli.  Occasionally  the  tibia  is  actually  twisted  on  its  long  axis,  so 
that  an 'osteotomy  may  be  required  in  order  to  overcome  the  deformity. 

Malleotomy. — In  confirmed  club  foot,  of  the  type  under  considera- 
tion, the  chief  obstacle  to  perfect  correction  is  often  the  astragalus.  This 
is  displaced  forward,  downward  and  inward,  only  the  posterior  portion 
of  its  articulating  surface  being  contained  between  the  malleoli.  Thus 
the  space  between  the  two  bones  may  have  become  insufficient  for  the 
anterior  and  wider  part  of  the  body  of  the  astragalus.  In  such  cases, 
even  after  division  of  the  teudo  Achillis  and  the  posterior  ligament  of 
the  ankle,  dorsal  flexion  still  remains  restricted  and  examination  shows 
that  the  astragalus  still  projects  as  before,  even  though  the  foot  has 
been  forced  into  a  position  of  apparent  dorsi-flexion  and  abduction. 
This  apparent  correction  is  the  result  of  over-correction  at  the  medio- 
tarsal  joint,  of  outward  rotation  of  the  tibia  upon  the  femur  and  of 
backward  displacement  of  the  fibula. 

In  such  instances  the  malleoli  may  be  separated  from  one  another 
by  dividing  the  ligaments  that  hold  them  in  apposition.  A  straight 
incision  about  two  inches  long  is  made  directly  over  the  anterior  as- 
pect of  the  articulation,  the  ligaments  are  divided  and,  by  inserting 
a  thin  chisel,  the  bones  are  pried  apart,  while  the  astragalus  is  replaced 
in  the  proper  position.  This  is  usually  easy  if  the  restraining  tissues 
on  the  posterior  part  of  the  ankle  have  been  divided.  The  wound  is 
then  closed  and  the  foot  held  in  the  over-corrected  position  by  a  plaster 
bandage.  Complete  correction  of  the  varus  deformity  should,  of 
course,  precede  this  operation. 

It  might  seem  on  first  consideration  that  if  immediate  correction 
of  deformity  could  be  so  easily  accomplished  in  the  confirmed  cases, 
it  should  be  employed  even  in  infancy.  There  are,  however,  practical 
reasons  against  it ;  first,  because  the  foot  is  so  small  that  it  cannot  be 
easily  manipulated,  second,  because  even  after  it  is  corrected  it  must 
be  supported  until  the  child  begins  to  walk,  and  third,  because  the  foot 
can  be  so  easily  straightened  without  an  operation,  which,  even  of  so 
slight  a  character,  is  sometimes  cause  of  much  anxiety  to  the  parents. 
For  these  reasons  although  immediate  reduction  of  deformity  is  a 
thoroughly  practical  and  safe  operation,  it  is  rarely  performed  until  a 
later  time. 

Subcutaneous  Tenotomy. 

The  division  of  tendons  and  other  tissues  by  the  subcutaneous 
method,  has  been  mentioned  incidentally  but  as  it  has  so  long  occu- 
pied an  important,  and  even  at  one  time  the  most  important,  place  in 
the  treatment  of  club  foot,  the  operation  and  its  effects  may  be  described 
somewhat  in  detail. 

Tenotomy,  as  has  been  stated,  is  performed  for  the  purpose  of  re- 
moving an  obstacle  to  the  correction  and  over-correction  of  deformity. 
In  the  acquired  or  paralytic  form  of  club  foot,  one  or  more  shortened 
tendons  may  be  the  chief  obstacles  to  reposition.  But  in  the  congenital 
form,  in  which  all  the  tissues  have  grown  into  deformity,  the  shortened 


592  DEFORMITIES  OF  THE  FOOT. 

tendons  are  oy  no  means  the  only  resistant  parts,  and  tenotomy  should 
be  considered  therefore,  merely  as  an  incident  in  correction.  In  the 
ordinary  treatment  of  infantile  club  foot,  tenotomy  may  often  be  dis- 
pensed with,  and  in  the  great  majority  of  cases  division  of  the  tendo 
Achillis  is  alone  required. 

When  the  tendon  has  been  divided,  the  deformity  is  immediately 
over-corrected ;  thus  the  two  extremities  are  separated  to  the  extent 
necessary  to  allow  the  improved  position.  At  the  end  of  three  weeks 
or  more,  or  at  the  time  when  the  first  plaster  bandage  is  removed,  the 
space  will  be  filled  with  new  material,  and  in  another  month  the  splice, 
which  will  be  somewhat  larger  and  thicker  than  the  normal,  should  be 
strong  enough  for  use.  The  slight  thickening  at  the  site  of  the  opera- 
tion may  be  felt  for  a  year  or  more,  but  for  all  intents  and  purposes, 
the  new  and  lengthened  tendon  is  perfectly  normal,  as  is  the  function 
of  the  muscle  of  which  it  is  a  part. 

The  process  of  repair  is  somewhat  as  follows  :  Immediately  after 
the  operation  the  space  between  the  divided  ends  of  the  tendon  is  filled 
or  partially  filled  with  blood ;  then  leucocytes  appear,  which  with 
those  in  the  blood  clot  serve  as  pabulum  for  the  plasma  cells  which 
migrate  from  between  the  fasciculi  of  the  tendon  and  from  the  tendon 
sheath.  The  fibrin  and  red  corpuscles  of  the  clot  are  absorbed,  the 
extremities  of  the  divided  tendon  soften  and  become  fused  with  the 
new  material,  which  begins  to  take  on  the^form  and  consistency  of  true 
tendon,  and  to  separate  itself  from  the  adherent  sheath.  This  new 
tendon,  according  to  Tubby,  differs  from  the  normal  structure  in  that 
the  fibrous  fasciculi  are  more  irregular  and  its  substance  is  more  like 
scar  tissue,  but  practically  it  is  perfectly  normal  in  its  appearance  and 
function. 

Since  the  tendon  sheath  serves  an  important  purpose  in  repair,  it 
should  be  disturbed  as  little  as  possible.  For  this  as  well  as  for  other 
obvious  reasons,  subcutaneous  tenotomy  of  the  tendo  Achillis,  which 
is  so  prominent  and  so  distinct  from  other  important  parts  is  to  be  pre- 
ferred ;  but  if  more  extensive  division  of  other  tendons  is  required,  the 
open  operation  is  often  indicated. 

Division  of  the  Tendo  Achillis. — For  this  operation  ansesthe- 
sis  is  usually  required,  preferably  by  means  of  nitrous  oxid  gas,  and 
it  is  hardly  necessary  to  state  that  surgical  cleanliness,  even  in  so 
slight  a  procedure,  is  essential. 

The  instrument  should  be  small  and  very  sharp  so  that  no  force  is 
required  in  the  operation ;  the  blade  should  be  as  long  as  the  tendon 
is  wide.  The  patient  is  turned  upon  the  side  or  to  the  prone  position, 
so  that  the  foot  may  be  held  with  the  heel  upward  by  the  left  hand. 
The  position  and  size  of  the  tendon  is  ascertained  by  careful  palpation, 
and  the  knife  is  then  inserted  to  its  inner  side,  at  about  the  level  of 
the  extremity  of  the  internal  malleolus.  The  flat  surface  of  the  blade 
is  held  parallel  to  the  tendon,  and  it  is  passed  beneath  it  until  its 
point  can  be  felt  beneath  the  skin  on  the  opposite  side.  The  edge  is 
then  turned  upward  and  the  tendon,  being  made  tense,  is  divided  by  a 


THE  CORRECTION  OF  CONFIRMED   CLUB  FOOT.  593 

sawing  ^motion  of  the  knife.  Wiien  the  division  is  complete,  as  indi- 
cated by  the  separation  of  the  divided  ends,  the  knife  is  withdrawn, 
and  the  minute  opening  in  the  skin,  from  which  there  is  usually  slight 
bleeding,  is  covered  with  a  pledget  of  aseptic  cotton.  The  foot  is 
forced  into  dorsal  flexion  and  is  securely  fixed  by  a  plaster  bandage. 
In  applying  the  dressing  one  should  take  care  that  no  pressure  is 
brought  upon  the  seat  of  operation,  as  this  might  interfere  with  the 
effusion  of  plastic  material.  As  soon  as  the  discomfort  attending  the 
operation  has  subsided  the  patient  is  encouraged  to  stand  and  to  walk. 
Functional  use,  far  from  retarding  repair,  is,  by  stimulating  the  cir- 
culation, an  important  agent  in  assuring  firm  and  rapid  union. 

Division  of  the  plantar  fascia  is  not  infrequently  necessary  and 
should  be  performed  subcutaneously.  The  tenotome  is  inserted  be- 
neath the  skin  at  about  the  center  of  the  concavity  to  one  or  the  other 
side  of  the  central  band  of  the  fascia,  which  is  divided  by  a  sawing 
motion  of  the  knife.  The  part  is  put  upon  the  stretch,  and  other  resist- 
ing bands  to  the  outer  and  inner  side  are  divided  in  the  same  manner ; 
the  cavus  is  then  corrected  by  manual  or  instrumental  force.  The  opera- 
tion like  that  upon  the  tendo  Achillis  is  practically  free  from  danger. 

Division  of  the  tibialis  anticus  is  not  often  necessary,  as  this 
tendon  offers  little  resistance  to  the  rectification  of  deformity  of  the 
ordinary  type. 

The  tendon  of  the  tibialis  posticus  may  be  divided  together  with 
that  of  the  tibialis  anticus  near  the  points  of  attachment.  If  the  oper- 
ation is  required,  it  may  be  combined  with  simultaneous  section  of  the 
(JALCANEO-SCAPHOID  LIGAMENT,  with  which  are  blended  the  anterior 
part  of  the  deltoid  and  fibers  of  the  anterior  ligament  of  the  ankle. 
("  The  Astragalo-Scaphoid  Capsule,"  Parker.)  According  to  Parker's 
directions,  the  foot  should  be  strongly  abducted  to  make  the  parts  tense. 
The  tenotome  is  entered  directly  in  front  of  the  anterior  border  of  the 
internal  malleolus,  its  cutting  edge  being  turned  forward  between  the 
skin  and  the  ligament.  It  is  then  turned  toward  the  ligament,  and  the 
tissues  are  divided  to  the  bone.  The  blade  is  then  made  to  enter  the 
interval  between  the  astragalus  and  the  scaphoid,  and  is  carried  down- 
ward and  forward  to  divide  the  inferior  part  of  the  ligament  and  at  the 
same  time  the  tendons  of  tibialis  anticus  and  posticus. 

The  posterior  ligament  of  the  ankle  joint  may  be  divided  or  suffi- 
ciently weakened,  so  that  it  may  be  ruptured  after  section  of  the  tendo 
Achillis  by  passing  the  knife  directly  downward  in  the  middle  line 
upon  the  upper  border  of  the  astragalus. 

The  Correction  of  Confirmed  Club  Foot  by  the  Method 
of  Julius  Wolff. 

Wolff's  treatment  of  club  foot  as  described  by  Freiberg,  a  former 
assistant  in  his  clinic,  may  be  summarized  as  follows  :  ^  The  patient 
is  anaesthetized,  and   with  the  hands  and   by  the  use  of  a  moderate 

'  Med.  News,  Oct.  29,  1892. 
38 


594 


DEFORMITIES  OF  THE  FOOT. 


Fig.  416. 


amount  of  force,  the  deformity  is  reduced  as  far  as  possible.  The 
foot  is  held  in  the  improved  position  by  means  of  strips  of  ad- 
hesive plaster,  passing  from  the  dorsal  surface  of  the  inner  border  of 
the  foot  under  the  sole  and  up  to  the  outer  aspect  of  the  leg.  The 
leg  and  foot  are  then  covered  with  cotton  from  the  tuberosity  of  the 
tibia  to  the  tips  of  the  toes  and  a  plaster  bandage  is  applied.  As  the 
plaster  is  hardening,  the  position  of  the  foot  is  still  further  im- 
proved by  pressing  the  heel  inward  and  the  forefoot  outward  and  up- 
ward. Two  fenestra  are  cut  in  the  plaster  at  the  points  of  greatest 
pressure  ;  one  over  the  external  surface  of  the  ankle,  and  the  other  over 
the  internal  surface  of  the  great  toe.  If  tenotomy  is  considered  neces- 
sary, it  is  usually  performed  as  a  preliminary  operation  several  days 
before  forcible  correction. 

On  the  third  or  fourth  day  after  the  operation,  a  wedge-shaped  sec- 
tion is  cut  from  the  bandage  on  the  outer  side  of  the  ankle  joint  and  a 
linear  division  is  made  about  the  ankle,  so  that  the  leg  and  the  foot 
parts  of  the  bandage  are  separated.  (Fig.  416.)  The  leg  being  held 
firmly,  the  foot  is  forced  outward  and  upward  to 
the  extent  that  the  wedge-shaped  opening  in  the 
plaster  will  allow,  and  the  two  sections  are  then 
united  by  a  covering  of  plaster  bandage.  For  the 
secondary  correction  anaesthesia  is  not  required. 
At  intervals  of  several  days  larger  wedges  are  re- 
moved and  the  manipulation  is  repeated  until  the 
patient  stands  with  the  foot  in  a  satisfactory  atti- 
tude, that  is  in  pronation,  abduction  and  dorsi- 
flexion.  If  the  deformity  is  extreme  the  bandage 
may  be  reapplied  before  the  correction  is  com- 
pleted with  advantage.  One  should  take  care  that 
the  toes  are  not  compressed,  but  lie  on  the  same 
plane,  in  normal  relation  to  one  another.  When 
rectification  is  complete  the  plaster  bandage  is 
covered  with  strips  of  pine  shavings,  held  in  place 
by  a  crinoline  bandage,  and  painted  with  carpen- 
ter's glue.  When  this  is  hardened,  the  whole  is 
covered  with  a  thin  silicate  bandage ;  over  this, 
the  shoe  is  fitted  and  the  patient  is  encouraged  to 
walk.  This  form  of  dressing  is  used  until  the  trans- 
formation of  the  deformed  parts  may  be  supposed 
to  be  complete,  the  time  varying  with  the  case,  from  a  few  weeks  to  a 
year.  The  time  required  for  the  primary  correction  is  from  a  week  to 
a  month.  When  the  bandage  is  finally  removed,  massage  and  exer- 
cises are  to  be  employed. 

Wolff's  treatment  has  been  thoroughly  tested  at  the  Hospital  for 
Ruptured  and  Crippled.  It  is  an  efficient  means  of  correction  al- 
though somewhat  tedious.  It  may  be  more  conveniently  employed 
in  later  childhood  and  adolescence  than  at  an  earlier  age. 


The  points  at  which  the 
bandage  is  divided  and  the 
wedge  removed.  (Frei- 
berg.) 


THE  THOMAS  METHOD. 


595 


Fig.  417. 


Forcible  Correction  of  Deformity  by  Means  of  Osteoclasts 
and  Wrenches. 

In  place  of  manual  correction  greater  force  may  be  employed  by  means 
of  wrenches  or  osteoclasts  to  overcome  the  deformity.  There  is  this 
important  difference  between  the  two  procedures  :  force  may  be  applied 
by  the  hands  for  as  long  a  time  as  is  necessary  without  fear  of  injury, 
while  force  applied  by  a  machine  must  be  momentary  because  of  the 
pressure  and  strain  on  the  parts  where  the  leverage  is  exerted.  Manual 
force  continuously  applied  may  be  supposed  to  stretch  the  resistant 
parts,  and  although  much  less  power  is  exerted  it  is  really  more  effec- 
tive than  the  sudden  and  momentary  force  of  the  wrench  or  osteoclast. 
By  manual  rectification  the  operation  may  be  continued  until  the  de- 
formity has  been  over-corrected,  while  complete  correction  by  means  of 
instruments  may  necessitate  several 
operations. 

The  Thomas  Method.— Of  in- 
strumental correction,  that  by  means 
of  the  Thomas  wrench  is  one  of  the 
simplest  and  most  efficient.  The 
wrenching  may  or  may  not  be  pre- 
ceded by  tenotomy,  a  point  to  be  de- 
cided by  the  resistance  of  the  parts. 
As  a  rule  division  of  the  tendo 
Achillis  is  alone  necessary.  The  in- 
strument is  a  simple  heavy  monkey 
wrench,  of  which  the  jaws  have 
been  replaced  by  two  strong  pins 
slightly  bulbous  at  the  ends  to  keep 
the  covers  of  rubber  tubing  from 
slipping  off. 

The  wrench  is  applied  to  the  in- 
ner side  of  the  foot  and  screwed 
down  so  that  it  may  "  bite "  and 
hold  its  place  firmly,  for  if  it  slips  it 
is  likely  to  abrade  or  tear  the  skin  ; 
then  with  considerable  force  the 
foot  is  twisted  outward  and  upward. 
(Fig.  417.)  The  "key  note"  of 
the  operation  is  to  so  wrench  the 
foot  that  it  loses  its  elasticity,  and 
shows  no  tendency  to  recoil  toward 
deformity.     The  foot  is  then  placed 

in  the  best  possible  position  and  is  retained  there  by  the  Thomas 
foot  splint  or  by  a  plaster  bandage.  In  certain  instances  one  may 
complete  the  rectification  at  one  operation,  but  this  not  usually  at- 
tempted, the  procedure  being  repeated  at  intervals  of  a  few  days  until 
the  deformity  has  been  over-corrected.     In  very  resistant  cases,  eight 


The  Thomas  wrench  as  used  in  the  correction 
of  club  foot. 


596 


DEFORMITIES   OF  THE  FOOT. 


or  ten  applications  of  force  may  be  necessary.  When  the  deformity 
has  'been  rectified,  the  foot  is  held  in  the  over-corrected  position  for 
several  weeks  by  the  splint  or  by  the  plaster  bandage. 

As  a  walking  appliance  a  simple  upright  of  iron  with  a  calf  band  is 
applied  to  the  inner  side  of  the  leg,  from  a  point  just  below  the  knee  to 
the  heel  of  the  shoe  into  which  it  is  inserted,  as  is  the  Thomas  knock 
knee  brace.  (Fig.  293.)  By  bending  the  upright  the  foot  may  be 
kept  in  slight  valgus,  and  this  position  is  still  further  assured  by  mak- 
ing the  outer  side  of  the  sole  of  the  shoe  thicker  than  the  inner  so  that 
the  weight  falls  upon  the  inner  border  of  the  foot.     In  many  instances, 

the  walking  brace  may  be 
YiG.  418.  dispensed  with  in  the  after- 

treatment,  but  a  light  brace 
is  usually  worn  to  hold  the 
foot  in  the  corrected  position 
during  the  night,  until  the 
power  of  the  abductors  and 
dorsal  flexors  has  been  re- 
gained. Massage  and  ma- 
nipulation are  used  in  the 
after-treatment  in  the  man- 
ner already  described. 

Properly  applied  the  treat- 
ment is  satisfactory  and  free 
from  danger.  Sloughing  of 
the  tissues  caused  by  the 
pressure  of  the  instrument 
or  by  the  plaster  bandages 
has  been  reported,  but  such 
accidents  have  not  occurred 
in  the  extensive  practice  of 
Thomas  and  Jones. 

Correction  by  Means  ,of 
the  Osteoclast. — The  late 
Mr.  Grattan,  of  Cork,  used 
the  osteoclast  that  goes  by 
his  name  (Fig.  296)  to  crush 
and  to  over-correct  resistant 
club  foot.  The  operation  may  include  beside  the  correction  of  the  de- 
formity of  the  foot  itself,  fracture  of  the  leg  above  the  malleolus,  to 
turn  the  foot  toward  valgus,  and  a  second  fracture  half-way  up  the 
limb,  to  overcome  the  inward  rotation  or  twist  of  the  tibia.  Mr.  Grat- 
tan's  results  have  been  very  satisfactory.  Other  appliances  constructed 
on  somewhat  similar  principles  may  be  employed.  Of  these,  the  Lor- 
enz  osteoclast^  and  the  Bradford^  lever  apparatus  are  the  most  effective. 
The  Open  Incision  Combined  with  Forcible  Rectification  of  De- 
formity.    Phelps'  Operation. — When  extensive  division  of  contracted 


Kesistant  club  foot  iu  later  childhood. 
(See  Fig.  419.) 


1  Wiener  Klinik,  Nov.-Dec,  1895. 


•Bradford  and  Lovett,  2d  ed.,  p.  414. 


PHELPS'    OPERATION. 


597 


Fig.  419. 


parts  is  indicated,  the  open  incision  is  to  be  preferred  because  of  the 
opportuiiity  thus  offered-  for  the  recognition,  and  for  intelligent  selec- 
tion, of  structures  that  require  division  in  the  final  correction  of  the 
deformity. 

Phelps'  operation  is  essentially  simply  the  division  of  resistant  parts 
through  an  incision  on  the  inner  border  of  the  foot,  combined  with 
sufficient  force,  manual  or  instrumental,  to  over-correct  the  deformity. 
It  is  the  most  conservative  of  the  more  radical  procedures,  and  by  it 
even  the  most  severe  type  of  deformity  in  the  adult  can  be  corrected  ; 
that  is  to  say,  the  deformity  may  be  overcome  and  a  serviceable  foot 
may  be  assured  to  the  patient.  Perfect  functional  cure  is  not  possible 
when  deformity  has  become  habitual  after  many  years  of  neglect. 

The  steps  of  the  Phelps  operation  are  as  follows :  After  proper  sur- 
gical preparation  the  Esmarch  bandage  is  applied.  The  tendo  Achillis, 
and  usually  the  posterior  liga- 
ment of  the  ankle,  are  divided 
subcutaneously,  and  by  manual 
or  instrumental  force  one  at- 
tempts to  correct  the  plantar  flex- 
ion. An  incision  is  then  made 
on  the  inner  border  of  the  foot, 
just  below  and  in  front  of  the 
internal  malleolus,  which  is  ex- 
tended directly  downward  over 
the  head  of  the  astragalus  to  in- 
clude the  inner  quarter  of  the 
sole.  Through  the  incision  all 
resistant  parts  are  divided  in 
order,  as  stated  by  Phelps. 

1.  The  tibialis  posticus,  and 
the  anticus,  if  it  offers  resistance. 

2.  The  abductor  pollicis. 

3.  The  plantar  fascia, 

4.  The  flexor  brevis  digitorum. 

5.  The  long  flexor  of  the  toes. 

6.  The  deltoid  ligament  in  all 
its  branches. 

During  the  successive  division 
of  the  tissues,  repeated  attempts 
are  made  to  correct  the  foot,  and 
only  those  structures  are  divided 

that  present  themselves  as  tense  and  resistant  tissues  when  the  foot  is 
forcibly  abducted. 

In  the  adult  type  of  club  foot  no  particular  effort  is  made  to  recog- 
nize the  different  structures,  but  all  the  tissues  on  the  inner  side  of  the 
foot  including  blood  vessels  and  nerves,  the  deep  ligaments,  and  oc- 
casionally the  tendon  of  the  peroneus  longus  muscle,  are  divided. 
Even  then  it  is  necessary  to  apply  considerable  force  to  correct  the  de- 


■■ 

KIL^ 

BHWW||y|i^K->'    A**^ 

pi 

flfff'^l^j^n 

1 

1 

C^Lfl 

1 

The  deformit}^  (Fig.  418)  corrected  by     Phelps' 
operation  and  by  cuneiform  osteotomy  of  the  os 
calcis. 


598 


DEFORMITIES  OF  THE  FOOT. 


formity.  In  certain  instances  the  rectification  of  deformity  necessitates 
osteotomy  of  the  neck  of  the  astragalus,  or  the  removal  of  a  cuneiform 
section  from  the  os  calcis.  The  object  of  the  Phelps  operation  is,  by 
the  use  of  force  and  by  division  of  resistant  tissues,  to  over-correct  the 
deformed  foot  at  one  sitting,  and  as  much  force  and  as  extensive  di- 
vision of  tissues  as  are  required,  should  be  employed  by  the  operator. 
AVhen  the  foot  can  be  held  in  the  desired  position  without  resist- 
ance, the  wound  is  covered  with  Lister  protective,  the  foot  and  leg 
are  thickly  covered  with  gauze  and  cotton,  a  plaster  bandage  is  applied 

and  the  limb  is  elevated.  The 
Fig.  420.  large  gaping  wound  closes  by 

granulation  in   from  one  to 
three  months. 

By  this  operation  the  foot, 
even  in  severe  cases  in  adult 
life,  may  be  made  straight  in 
appearance.  It  is  evident, 
however,  that  in  such  cases 
the  correction  of  the  defor- 
mity of  the  bones  is  by  no 
means  always  perfect,  for  the 
forefoot  may  be  simply  twist- 
ed outward  and  upward  while 
the  astragalus  and  os  calcis 
may  remain  in  an  approxi- 
mation to  their  original  de- 
formity. After  thorough 
over-correction  by  the  Phelps 
operation  the  danger  of  re- 
currence of  deformity  in  the 
adult  and  adolescent  type  of 
club  foot  is  not  great,  and 
in  many  instances  support 
other  than  that  of  the  plaster 
bandage  for  several  months 
after  the  operation  may  be 
unnecessary  ;  but  in  childhood  the  ordinary  precautions  in  after-treat- 
ment to  prevent  relapse  will  be  necessary. 

Malleotomy  may  be  employed  with  advantage  in  connection  with 
this  operation.     (See  page  590.) 

Operations  on  the  Bones. 

Osteotomy  of  the  neck  of  the  astragalus,  as  a  supplementary  part  of 
the  operation  of  forcible  correction,  has  been  mentioned.  In  certain 
instances,  particularly  in  the  adolescent  or  adult  type  of  deformity,  the 
displaced  astragalus  may  oifer  such  an  obstacle  to  correction  that  its 
removal  is  indicated — an  operation  first  performed  by  Mr.  Lund,  of 
Manchester. 


Resistant  club  foot  in  later  childhood. 
(See  Fig.  421.) 


CUNEIFORM  OSTEOTOMY. 


599 


Astragalectomy. — The  astragalus  is  usually  removed  by  means  of 
an  inei^ion  passing  over  its  most  prominent  part,  in  a  direction  for- 
ward and  downward  from  the  tip  of  the  external  malleolus,  between 
the  tendons  of  the  peroneus  brevis  and  tertius.  The  soft  parts  are 
drawn  aside,  the  ankle  and  astragalo-scaphoid  joint  are  opened  and  the 
attachments  to  the  scaphoid,  and,  as  far  as  possible,  those  at  the  inner 
and  outer  border,  are  divided.  The  foot  is  then  adducted  so  that  the 
head  of  the  bone  may  be  seized  with  forceps  and  drawn  upward,  the 
interosseous  ligament  and  the  internal  lateral  ligament  may  be  divided 
with  curved  scissors  and  the  bone  may  be  removed.  If  after  removal 
of  the  astragalus  the  deformity  can  not  be  corrected,  the  anterior  part 


Fig.  422. 


Fig.  421. 


After  forcible  correction  and  astragalec- 
tomy.    (See  Fig.  420.) 


Partially  corrected  club  foot  showing  secon- 
dary Icnock  knee. 


of  the  OS  calcis  or  the  external  malleolus  should  be  removed  as  well. 
A  useful  movable  foot  may  be  obtained  by  this  operation,  but  it  by  no 
means  assures  the  patient  from  recurrence  of  deformity.  It  is  never 
indicated  as  a  primary  operation.  The  varus  should  be  thoroughly  cor- 
rected as  a  preliminary  procedure ;  then  the  resistance  that  the  astrag- 
alus offers  to  dorsal  flexion,  can  be  estimated.     (Fig.  4'2].) 

Cuneiform  Osteotomy. — The  removal  of  cuneiform  sections  of  bone 
from  the  outer  border  of  the  foot  is  sometimes  necessary,  but  the 
operation  should  be  secondary  to  other  methods  of  correction.  The 
aim  should  be  to  lengthen  contracted  and  shortened  tissues  on  the 
inner  border  of  the  foot,  to  the  extent  required  for  reposition  ;  not 


600  DEFORMITIES  OF  THE  FOOT. 

to  remove  bone  to  accommodate  these  shortened  tissues.  If  this  has 
been  shown  to  be  impossible  by  ordinary  means,  then  removal  of 
bone  may  be  indicated,  but  this  is  not  often  necessary  in  childhood  or 
even  in  adolescence.  If  sufficient  bone  is  removed  from  the  adult 
foot  to  allow  of  perfect  correction  of  the  deformity,  relapse  is  not 
usual ;  but  in  childhood,  as  has  been  stated,  no  operation  will  take  the 
place  of  after-treatment. 

The  treatment  by  cuneiform  osteotomy  as  it  is  ordinarily  carried  out 
is  sufficiently  simple.  In  severe  cases,  the  astragalus  is  usually  re- 
moved and  a  wedge-shaped  section  of  bone  is  taken  from  the  os  calcis, 
cuboid,  and  if  necessary  it  may  include  the  scaphoid  bone  also.  The 
external  malleolus  may  be  removed,  if  it  interferes  with  reposition. 
Preliminary  fasciotomies  and  tenotomies  are  usually  performed,  but 
those  who  favor  this  method  of  treatment  rarely  use  force  in  reposition. 
In  less  advanced  deformity  the  astragalus  is  not  removed  but  a  part  of 
its  body  and  neck  is  included  in  the  cuneiform  resection.  The  foot  is 
retained  in  proper  position  until  the  wounds  are  closed ;  then  plaster 
bandages  are  employed  for  several  months.  Braces  are  seldom  used 
in  the  after-treatment. 

Secondary  Osteotomy. — In  certain  cases  of  relapsed  or  ineffect- 
ively treated  club  foot,  even  in  childhood,  deformity  of  the  os  calcis 
either  interferes  with  correction  of  the  foot  or  favors  relapse.  In  such 
instances  the  removal  of  a  cuneiform  section  of  bone  from  the  anterior 
extremity,  as  a  supplementary  part  of  over-correction,  may  be  of  service. 

Simple  Mechanical  Rectification  of  Deformity  in  Walking 
Children  and  in  Later  Years. 

It  has  been  stated  that  simple  mechanical  rectification  of  deformity 
was  possible  even  up  to  adolescence,  but  that  the  time  required  for 
such  treatment,  usually  extending  over  several  years,  as  a  rule  ex- 
cluded it  from  consideration. 

The  simplest  mechanical  treatment  is  that  by  which  the  foot  is 
slowly  forced  from  equino-varus  into  equino-valgus  by  a  brace  on  the 
lever  principle,  which  is  at  first  sliaped  to  the  deformity,  and  is  then 
gradually  straightened  as  the  resistance  diminishes.  "When  the  mid- 
point has  been  passed  between  varus  and  valgus  the  weight  of  the 
body  aids  in  the  correction  of  the  remaining  varus  and  equiuus.  The 
modification  of  the  Taylor  brace  used  by  Judson,  an  advocate  of  pure 
mechanics  in  the  treatment  of  club  foot,  will  serve  to  illustrate  the 
type  of  apparatus  which,  with  slight  change,  may  be  employed  to 
correct  or  to  support  the  weakened  or  deformed  foot. 

The  brace  consists  of  an  upright,  a  flat  tapering  bar  of  mild  steel,  a 
foot-plate  of  steel  from  18  to  16  gauge,  and  a  strong  calf  band.  The 
shape  of  the  brace,  the  method  of  its  attachment  to  the  leg  by  straps 
of  webbing  and  its  effect  in  gradually  changing  the  attitude  of  the 
foot  from  varus  to  valgus  are  shown  in  the  accompanying  figures. 

The  upright  is  firmly  riveted  to  the  foot-plate  in  the  angle  of  de- 
formity, so  that  the  patient  must  walk  upon  his  toes ;  as  the  equinus 


SIMPLE  MECHANICAL  RECTIFICATION   OF  DEFORMITY.      601 
Fig.  423.  Fig.  424. 


^ 


The  Judson  brace.  Fig.  423  shows  the  construction  of  the  brace  ;  the  foot  plate  with  the  internal 
flange  or  "riser,"  the  upright  riveted  firmly  to  it,  and  the  calf  band.  Fig.  424  shows  the  brace  ad- 
justed to  fit  the  deformed  foot. 


Fig.  425. 


Fig.  426. 


Fig.  427. 


Showing  the  progressive  reduction  of  deformity.  Fig.  42.5  shows  the  ordinary  attitude  of  the  neg- 
lected club  foot  in  childhood  with  the  adjustment  of  the  brace,  it  being  beut  to  accommodate  the 
deformity.  Fig.  426  shows  additional  details — an  uprightspur  useful  in  holding  the  heel,  and  for  the 
attachment  of  straps  ;  the  spur  of  sheet  brass  that  maybe  bent  over  the  great  toe  to  hold  it  in  position. 
Fig.  427  shows  other  details  in  the  method  of  attachment,  a  strip  of  adhesive  plaster  with  two  tails  in 
the  place  of  the  band  of  webbing.    This  aids  in  fixing  the  heel.     (See  Figs.  428,  429.) 


602 


DEFORMITIES  OF  THE  FOOT. 


is  decreased  by  the  influence  of  the  weight  of  the  body,  this  angle  is 
lessened.      (Fig.  423.) 

The  important  points  are,  that  the  brace  should  be  strong  enough  to 
hold  its  place  under  the  strain  of  use,  and  that  the  foot  shall  be  firmly 
secured  to  it,  whether  one  or  many  straps  of  webbing  are  required,  as 
may  be  seen  in  the  figures.  The  use  of  massage  and  manipulation  is 
of  course  combined  with  the  mechanical  treatment. 

By  persistent  attention  to  the  details  of  treatment  satisfactory  results 
can  be  obtained  by  this  method  in  the  less  resistant  cases,  even  in 
adolescence. 

Recapitulation  of  the  Principles  of  Treatment  of  Congenital 
Talipes  Equino-Varus. 

The  object  of  treatment  is  to  overcome  and  to  over-correct  the  de- 
formity, at  as  early  a  period  of  life  as  is  possible,  and  as  quickly  as 
possible.  The  object  of  over-correction  is  to  overcome  all  the  resist- 
ance of  the  tissues  that  may 


Fig.  428. 


Fig.  429. 


even  in  the  slightest  degree 
limit  the  normal  range  of  mo- 
tion in  any  direction.  The 
foot  must  be  supported  in  the 
over-corrected  position  until 
the  recoil  of  the  tissues  toward 
deformity  is  no  longer  present. 
It  must  be  supported  in 
the  proper  relation  to  the  leg, 
and  at  a  right  angle  with  it, 
until  the  muscular  balance 
has  been  reestablished  by 
stimulation  of  the  weaker, 
and  by  limitation  of  the  ac- 
tivity of  the  stronger,  muscles, 
and  until  transformation  of 
the  internal  structure  has  been 
completed. 

If  efficient  mechanical 
treatment  is  applied  at  the 
proper  time,  that  is  to  say,  in 
earliest  infancy,  no  operation, 
other  than  division  of  the 
tendo  Achillis,  will  be  re- 
quired. 

If  the  deformity  is  not  cor- 
rected or  is  but  partially  cor- 
rected, when  the  child  has  begun  to  walk,  some  form  of  operation  is  as 
a  rule  indicated ;  but  division  of  the  resistant  tissues  must  always  be 
combined  with  the  employment  of  sufficient  force  to  accomplish  the  de- 
sired result,  viz.,  over-correction  of  the  deformity.   Forcible  manual  cor- 


Showing  the  progressive  reduction  of  deformity, 
and  illustrating  the  process  of  changing  the  shape  of 
the  brace  from  time  to  time  until  it  holds  the  foot  in 
valgus.    (See  Fig.  425.) 


CONGENITAL   TALIPES   VARUS.  603 

rection,  applied  in  the  manner  described,  is  the  most  efficient  means  of 
attaining  this  object.  No  instrument  can  equal  the  hand,  and  the  force 
that  can  be  applied  by  the  hand  is  sufficient  in  all  the  ordinary  cases 
in  early  childhood,  and  in  combination  with  subcutaneous  division  of 
the  more  resistant  tendons  and  ligaments,  even  in  later  childhood  and 
adolescence. 

Forcible  correction  by  the  Thomas  wrench  under  the  same  condi- 
tions, is  an  efficient  treatment,  but  there  is  a  manifest  disadvantage  in 
submitting  a  patient  to  a  succession  of  operations,  even  of  so  slight  a 
character,  if  immediate  over-correction  can  be  attained  by  other  means. 

The  Phelps  operation,  which  combines  thorough  division  of  the  re- 
sistant parts  with  the  application  of  proper  force  to  over-correct  the 
foot,  is  the  operation  of  selection  for  the  more  resistant  cases  in  ado- 
lescence, in  adult  life,  and  in  extremely  resistant  cases  in  childhood. 

Astragalectomy  and  cuneiform  osteotomy  are  never  indicated  as  pri- 
mary operations,  but  one  or  the  other  may  be  necessary  for  the  com- 
plete rectification  of  the  deformity  when  other  means  have  failed. 

Complete  cure  of  deformity,  even  in  the  later  years  of  childhood,  is 
possible  by  means  of  braces  alone,  but  such  treatment  is  very  tedious. 
It  requires  not  only  the  continuous  supervision  of  the  skilled  surgeon, 
but  the  intelligent  and  persistent  cooperation  of  the  parents.  The  re- 
sults are  in  no  way  superior  to  those  attained  by  more  rapid  methods, 
while  the  disadvantages  of  long-continued  use  of  braces  are  sufficiently 
obvious.  To  the  popular  faith  in  braces  as  a  cure-all  of  deformity,  and 
to  the  unintelligent  use  of  braces,  may  be  ascribed  now,  as  in  former 
times,  the  failure  of  treatment  of  this  eminently  curable  deformity. 
This  statement  seems  justified,  even  when  balanced  by  the  equally 
fallacious  belief,  so  prevalent  among  physicians,  that  a  radical  opera- 
tion, if  it  does  not  absolutely  assure  a  cure,  is,  at  least,  the  essential 
part  of  the  treatment. 

Rectification  of  deformity,  by  whatever  means,  simply  completes  the 
first  stage  of  treatment.  Perfect  cure  can  only  be  assured  by  attention 
to  the  small  details  of  after-treatment,  by  checking  the  slightest  im- 
pulse toward  deformity,  and  by  guiding  the  unbalanced  foot  toward 
perfect  functional  use. 

Other  Varieties  of  Congenital  Talipes. 

Forms  of  congenital  distortion  of  the  foot  other  than  equino-varus 
are  not  uncommon,  but  as  a  rule  these  deformities  are  so  slight,  and,  as 
compared  to  equino-varus,  so  easily  remedied  that  they  are  relatively 
of  little  importance.  This  distinction  does  not  apply  however  to  ac- 
quired talipes  which  will  be  considered  in  the  succeeding  chapter. 

Congenital  Talipes  Varus. 

Eighty -five  cases  of  simple  varus  are  recorded  in  the  table  of  statis- 
tics in  a  total  of  sixteen  hundred  and  sixty  congenital  deformities  of 
the  foot. 


601  DEFORMITIES  OF  THE  FOOT. 

This  deformity  often  appears  to  be  an  incomplete  form  of  equino- 
varus,  but  in  some  instances  there  is  simply  a  slight  inward  twist  of 
the  foot  without  supination  (Fig.  376)  ;  in  fact,  the  forefoot  seems  to 
be  drawn  inward  by  the  active  movement  of  the  great  toe,  which,  in 
such  cases,  seems  almost  prehensile.  (See  pigeon  toe.)  In  the  more 
marked  form  the  foot  is  adducted  and  supinated,  and  the  tissues  are 
very  resistant. 

The  slight  grades  of  deformity  may  be  treated  by  simple  manipula- 
tion, and  if  deformity  remains  after  the  first  year,  the  shoe  will,  as  a 
rule,  correct  it.  The  more  marked  varieties  must  be  treated  like  the 
varus  deformity  of  ordinary  club  foot,  by  braces  or  by  plaster,  until  the 
varus  has  been  transformed  into  valgus.  The  after-treatment  is  the 
same  as  that  for  ordinary  club  foot. 

Congenital  Talipes  Equinus. 

This  is  a  rare  congenital  deformity,  about  half  as  common,  accord- 
ing to  the  statistics,  as  varus  (40  cases  in  1,660).  The  term  equinus 
implies  that  dorsal  flexion  is  limited,  but  that  the  foot  is  not  deviated 
to  one  or  the  other  side  (toward  valgus  or  varus).  In  congenital 
equinus  the  deformity  is,  as  a  rule,  slight,  and  in  many  instances  it 
may  be  overcome  by  gentle  manual  force  applied  frequently.  In  the 
more  resistant  type,  mechanical  correction,  or  tenotomy,  followed  by 
over-correction  and  support,  may  be  necessary. 

Congenital  Talipes  Calcaneus. 

Congenital  calcaneus  is  comparatively  rare  (28  cases  in  1,660).  As  a 
rule  the  heel  is  prominent,  the  foot  is  habitually  dorsi-flexed,  and  the 
dorsum  can  be  easily  brought  into  contact  with  the  crest  of  the  tibia. 
(Fig.  386.)  The  exaggerated  cavus,  that  is  usually  present  in  acquired 
calcaneus,  is  absent.  Occasionally  the  deformity  is  accompanied  by 
hyper-extension  of  the  knee,  and  if,  as  in  many  instances,  there  is  a  his- 
tory of  breech  presentation,  it  may  be  inferred  that  the  attitude  before 
birth  was  one  of  extreme  flexion  of  the  thighs  upon  the  abdomen,  the 
anterior  surfaces  of  the  extended  legs  being  pressed  closely  to  the  ven- 
tral surface  of  the  body,  the  feet  being  fixed  in  an  attitude  of  dorsi-flexion. 
As  a  rule  the  deformity  is  slight,  and  the  resistance  of  the  tissues  on  the 
anterior  aspect  of  the  leg  can  be  easily  overcome  by  massage  and  man- 
ipulation. The  foot  should  be  gently  forced  toward  plantar  flexion 
several  times  in  the  day,  and  the  weak  muscles  of  the  calf  should  be 
stimulated  by  massage. 

Cure  may  be  hastened  by  the  use  of  some  simple  form  of  retention 
splint  to  hold  the  foot  in  plantar  flexion  until  the  posterior  group  of 
muscles  has  recovered  its  power.  Tenotomy  or  other  operative  treat- 
ment is  rarely  required.  In  rare  instances,  the  tibia  may  be  bent 
slightly  backward,  thus  increasing  the  deformity.  In  such  cases 
the  distortion  of  the  bone  may  be  overcome  by  manipulation  and  by 
apparatus. 


CONGENITAL   TALIPES   VALGUS. 


605 


Congenital  Talipes  Valgus. 

Congenital  valgus  (Fig.  387)  is  somewhat  more  common  than  the 
preceding  varieties  (123  in  1,660).  Not  infrequently  it  is  combined 
with  a  slight  degree  of  calcaneus  or  equinus.  The  resistance  of  the 
contracted  tissues  is  not  great  and  the  deformity  may  be  overcome,  in 
most  cases,  by  persistent  manipulation.  If  the  muscular  power  is  suffi- 
ciently unbalanced  to  warrant  it,  the  foot  should  be  held  in  the  over- 
corrected  position  (varus)  for  some  time. 

Congenital  valgus  is  one  form  of  what  is  known  as  weak  ankle,  and  it 
frequently  passes  unnoticed  until  the  child  begins  to  walk.  If  at  that 
time,  in  spite  of  massage,  the  muscles  appear  weak  or  the  foot  inclines 
outward  when  weight  is  borne,  it  is  well  to  make  the  sole  of  the  shoe 

Fig.  430. 


Congenital  calcaneo-valgus. 

wedge  shaped,  the  thicker  part  (one-quarter  of  an  inch)  on  the  inner 
side.  In  more  persistent  cases,  a  brace  may  be  necessary,  as  described 
in  the  treatment  of  the  acquired  variety.     (See  the  weak  foot.) 

Talipes  equino-valgus  is  less  common  (28  in  1,660).  This  must 
be  treated  as  the  other  varieties,  by  complete  over-correction  of  de- 
formity, manual  or  otherwise,  and  by  subsequent  massage  and  support 
if  necessary. 

Calcaneo-valgus  (15  in  1,660),  calcaneo-varus  (7  in  1,660),  equino- 
cavus  (1  in  1,660),  valgo-cavus  (1  in  1,660),  cavus  (5  in  1,660),  are 
extremely  rare  as  indicated  by  the  statistics.  If  treated  early,  by  per- 
sistent massage  supplemented  by  retention  apparatus,  these,  as  well  as 
nearly  all  slighter  grades  of  congenital  deformity,  may  be  corrected 
and  cured  even,  before  the  child  begins  to  walk. 


606 


DEFORMITIES  OF  THE  FOOT. 


Congenital  Deformities  of  the  Foot  Associated  with  Defective 

Development. 

Talipes  Equino-Valgus  Associated  with  Congenital  Absence  of  Fibula. 
This  is  a  rare  deformity,  but  the  most  common  of  this  class.  The 
foot  at  birth  is  usually  in  an  attitude  of  well-marked  and  resistant 
equino-valgus.  The  leg  is  somewhat  shorter  than  its  fellow  and  the 
tibia  is  often  bent  sharply  forward,  sometimes  to  an  acute  angle,  at  a 
point  somewhat  below  the  center,  as  if  it  had  been  broken  in  utero. 
At  the  most  prominent  point  the  skin  may  be  adherent  or  it  may  present 

Fig.  431. 


Congenital  equino-varus  with  deformity  of  the  great  toes. 

a  dimpled  appearance.  In  some  instances  the  formation  of  the  foot  is 
perfect,  but  more  often  one  or  more  of  the  outer  toes,  with  the  corre- 
sponding metatarsal  bones,  are  absent. 

Statistics. — Haudek  collected  from  the  literature  97  cases  ;  of  these 
46  were  in  males,  21  were  in  females  and  in  30  the  sex  was  not  re- 
corded. In  67  (69  per  cent.)  there  was  total  absence  of  the  fibula. 
In  30  the  defect  was  partial ;  of  the  lower  extremity  of  the  fibula  in 
17,  of  the  upper  extremity  in  9,  and  of  the  middle  in  2  cases.  In  27 
cases  both  fibulae  were  absent  or  defective ;  in  68  one  only,  the  right 
in  31,  the  left  in  25,  and  in  the  others  the  side  was  not  recorded.  In 
61  cases  toes  were  lacking,  and  in  these  cases  it  may  be  inferred  that 
the  corresponding  metatarsal  bones  were  absent  also.  The  fourth  and 
fifth  toes  were  absent  in  27  cases,  the  little  toe  alone  was  missing  in  15. 


TREATMENT.  607 

In  manv  instances,  as  is  usual  in  cases  of  defective  development,  de- 
formity of  other  parts  was  present ;  for  example  in  1 7  instances  the 
patella  was  absent  or  undeveloped,  and  in  11  the  upper  extremities 
were  defective/ 

Etiology. — The  cause  of  deformity  associated  with  absence  of  bone, 
may  be  either  an  original  defect  in  the  germ  or  it  may  be  due  to  inter- 
ference with  its  development.  In  some  instances  amniotic  adhesions 
may  be  one  of  the  predisposing  causes ;  the  sharp  bend  in  the  tibia, 
so  often  present,  may  be  due  to  the  lessened  resistance  of  the  defective 
part. 

Treatment. — The  indications  for  treatment  are  to  correct  the  de- 
formity of  the  foot  in  the  usual  manner.  The  bend  in  the  tibia  may 
be  straightened  by  manipulation  and  splinting,  or  by  osteotomy,  if 
necessary.  When  the  patient  begins  to  walk  the  foot  must  be  sup- 
ported. A  light  steel  upright  on  the  outer  side  of  the  leg,  provided 
with  a  T  strap  to  hold  the  leg  against  it,  will  supply  the  place  of  the 
missing  fibula.  The  growth  of  the  tibia  is  retarded,  and  a  final  short- 
ening of  three  or  more  inches  may  be  expected,  but  with  care  a  useful 
limb  may  be  assured. 

Talipes  Varus  or  Equino-varus  Associated  with  Congenital  Absence  of 
the  Tibia. — Defective  formation  of  the  tibia  is  much  less  common  than 
that  of  the  fibula.  Joachimsthal  ^  records  31  cases.  Of  the  25  cases  in 
which  the  sex  was  recorded,  17  were  males  and  8  females.  In  23  in- 
stances the  defect  was  of  one  side  ;  in  8  both  tibise  were  defective.  In 
most  cases  the  femur  is  somewhat  shortened  and  its  lower  extremity  is 
imperfectly  developed.  In  a  third  of  the  cases  the  patella  was  absent, 
and  in  many  instances  other  malformations  were  present.  In  nearly  all 
the  cases  there  was  flexion  contraction  at  the  knee  and  the  fibula  was 
dislocated  backward.  The  foot  is  practically  always  in  an  attitude  of 
varus.  The  toes  may  be  normal,  but  in  a  number  of  instances,  the 
great  toe  was  lacking.  In  possibly  a  third  of  the  cases  a  portion  of 
the  tibia,  usually  the  upper  extremity,  was  present. 

The  prognosis,  as  regards  a  useful  limb  is  extremely  bad.  The 
growth  of  both  the  thigh  and  the  leg  is  much  retarded,  and  it  is  almost 
impossible  to  balance  the  foot  upon  the  fibula  by  any  form  of  brace. 

The  ordinary  treatment,  after  the  correction  of  the  deformity  of  the 
foot,  has  been  to  resect  the  extremities  of  the  femur  and  the  fibula  to 
induce  anchylosis.  No  final  results  have  been  reported  but  it  may  be 
assumed  that  an  artificial  limb  would  provide  a  more  useful  support 
than  the  short  and  distorted  extremity. 

Congenital  Deficiency  and  Hypertrophy. — The  leg  bones  may  be  per- 
fectly formed,  but  one  or  more  bones  of  the  foot  itself  may  be  absent. 
In  these  cases,  after  the  reduction  of  the  deformity,  a  support  to  hold 
the  defective  foot  in  its  proper  relation  to  the  leg  must  be  used. 

1  Vide  also  Schworer,  Zeits.  fiir  Orth.  Chir.,  Vol.  III.,  p.  220.  Kempke,  Zeits.  fiir 
Orth.  Chir.,  Vol.  III.,  p.  93.  Gotten  &  Chute,  Boston  Med.  and  Surg.  Jour.,  Nos. 
8  and  9,  1898  (128  cases).  Mazzitelli,  Arch.  Ortopedia,  1898,  F.  5.  Boinet,  Kevue 
d'Orthopedie,  Nov.,  1899. 

2 Zeits.  fiir  Orth.  Chir.,  Vol.  III.,  p.  140. 


608  DEFORMITIES  OF  THE  FOOT. 

The  foot  may  be  divided  into  two  parts,  so  that  it  resembles  a  lobster 
claw.  Supernumerary  toes,  or  deficiency  of  toes,  or  hypertrophy  of 
one  or  more  of  the  toes,  with  or  without  corresponding  over-growth  of 
the  foot  or  leg,  are  not  extremely  uncommon. 

These  deformities  must  be  treated  on  ordinary  surgical  principles. 

Constricting  Bands. 

Tightly  constricting  bands  of  scar-like  tissue,  which  cause  deep  in- 
dentations in  the  flesh  of  the  foot  or  leg,  are  sometimes  seen.  These 
are  supposed  to  be  caused  by  amniotic  adhesions.  "  Spontaneous  am- 
putations "  of  toes,  or  of  the  foot  itself,  are  due  to  the  same  cause. 
(Fig.  390.) 

|In  ordinary  cases,  the  bands  require  no  treatment,  but  if  they  inter- 
fere with  the  nutrition  of  the  foot,  they  may  be  removed. 

Congenital  (Edema  of  the  Feet. 

In  rare  instances,  sometimes  in  combination  with  deformity,  the 
tissues  of  the  feet  appear  to  be  oedematous,  although  the  circulation 
seems  to  be  perfect.  The  condition  is  apparently  due  to  obstruction 
of  the  lymphatic  circulation. 

It  should  be  treated  by  massage  and  by  compression. 

Spina  Bifida  and  Talipes. 

Talipes,  coexisting  with  spina  bifida,  should  be  treated  as  are  other 
forms  of  club  foot.  If  paralysis  of  the  lower  extremities  be  present, 
as  is  often  the  case,  the  corrected  feet  must  be  supported  as  in  the  or- 
dinary forms  of  paralytic  deformity.' 

^  Uber  missbildungen  der  Menschilichen  Gliedmassen  und  ihre  entsteliungsweise, 
Klausner,  1900. 


CHAPTER   XXllI. 
DEFORMITIES    OF    THE    FOOT.— Continual. 

Acquired  Talipes. 

In  the  account  of  the  cougenital  deformities  of  the  foot  it  was  stated 
that  the  form  known  as  equino-varus  was  by  far  the  most  common, 
and  that  as  compared  with  it,  the  other  deformities  were  of  slight  im- 
portance. 

In  the  acquired  varieties  of  talipes,  the  equino-varus  deformity  is 
much  less  common,  the  proportion  being,  in  the  congenital  form,  77 
per  cent,  and  in  the  acquired  32,5  per  cent,  of  the  total  number.  Ac- 
quired equinus  comes  next  in  frequency,  26  per  cent.,  as  compared 
with  2.4  per  cent,  of  the  congenital  deformity,  and  every  variety  and 
combination  of  deformity  finds  its  representative  in  acquired  talipes,  as 
may  be  seen  in  the  tables.     (See  page  568.) 

The  Etiology  of  Acauired  Talipes. — The  cause  of  acquired  talipes  is 
almost  always  paralysis.  In  the  table  of  statistics,  it  will  be  seen, 
that  in  82.8  per  cent,  the  paralysis  was  of  spinal  origin  (anterior 
poliomyelitis).  In  11.3  per  cent,  it  was  cerebral,  the  talipes  being  a 
part  of  the  deformity  of  hemiplegia  or  paraplegia.  A  few  cases  were 
caused  by  local  disease  or  injury  of  the  nerves,  and  the  remainder,  or 
5.4  per  cent,  were  of  traumatic  origin. 

The  distinction  between  the  two  forms  of  talipes,  congenital  and  ac- 
quired, has  already  been  emphasized.  In  the  congenital  form  the  de- 
formity is  the  essential  disability,  for  when  deformity  has  been  over- 
come the  most  difficult  part  of  the  treatment  has  been  accomplished 
and  perfect  cure  may  be  expected.  In  the  acquired  form,  the  removal 
of  deformity  is  but  a. part  of  the  treatment,  and  perfect  cure  is  not  to 
be  expected,  except  in  that  small  proportion  of  cases  in  which  the 
primary  disease  of  the  spinal  cord  has  caused  no  permanent  injury  to 
its  structure,  or  in  which  the  deformity  was  the  result  of  some  slight 
or  passing  disability  or  disease.  Again,  congenital  deformity  cannot 
be  anticipated  or  prevented.  Acquire!  talipes  is  an  effect  of  paralysis 
only  when  protective  treatment  has  been  neglected.  It  is  a  result  there- 
fore that  may  be  foreseen  and  thus,  by  proper  treatment,  prevented. 

Development  of  Deformity. — The  characteristics  of  anterior 
poliomyelitis  are  described  elsewhere.  (Chapter  XVII.)  In  its  effect 
upon  the  foot  the  usual  sequence  is  somewhat  as  follows  :  Immediately 
after  its  onset  the  paralysis  is  usually  widespread,  affecting  the  entire 
leg  for  example  ;  then  follows  a  period  of  partial  recovery,  after  which 
the  amount  of  damage  that  the  spinal  cord  has  sustained  may  be  esti- 
39 


610  DEFORMITIES  OF  THE  FOOT. 

mated.  It  is  during  the  period  of  partial  recovery,  the  six  months  or 
more  following  the  attack,  that  contractions,  which  lead  to  deformity, 
appear.  If,  for  example,  the  anterior  group  of  leg  muscles  is  paralyzed, 
th^  foot  habitually  hangs  downward,  a  position  caused  by  the  force  of 
gravity  and  by  the  contraction  of  the  unaffected  posterior  group.  If 
this  attitude  is  allowed  to  persist,  the  tissues  accommodate  themselves 
to  the  new  position  ;  the  muscles  which  are  never  extended  to  their 
normal  limit,  become  structurally  shortened,  while  the  paralyzed  group 
becomes  elongated.  Even  within  a  few  weeks  after  the  onset  of  the 
paralysis,  the  evidences  of  advancing  deformity  are  plain.  The  con- 
tracted tissues  resist  passive  motion  in  the  directions  opposed  to  the 
habitual  attitude,  and  the  child  shows  evidence  of  pain  if  force  is  used 
to  increase  the  limited  range  of  motion.  As  has  been  stated  already, 
paralytic  talipes  is  an  unnecessary  deformity.  It  may  be  prevented 
by  supporting  the  paralyzed  part  in  a  right-angled  relation  to  the 
limb,  and  by  systematic  passive  exercise  throughout  the  entire  range 
of  normal  motions ;  thus  improper  attitudes  and  the  secondary  contrac- 
tions that  fix  the  foot  in  the  distorted  position  may  be  avoided. 

Anterior  poliomyelitis  is  most  common  during  the  second  year  of 
life,  or  when  the  child  has  already  begun  to  walk.  When  the  first 
and  more  general  effect  of  the  disease  has  passed  away,  the  child  again 
uses  the  disabled  limb  as  best  it  may,  thus  the  distortion  of  the  foot  is 
increased  and  confirmed  by  the  weight  of  the  body  and  by  functional 
use  in  the  abnormal  attitude. 

The  final  deformity,  in  a  particular  case,  can  be  predicted  from  the 
knowledge  of  the  function  of  the  muscle  or  muscles  which  has  been 
lost.  For  example,  paralysis  of  the  tibialis  anticus,  the  most  powerful 
dorsi-flexor  and  adductor  of  the  anterior  group,  must  result  in  equino- 
valgus.  If  the  peroneus  brevis  and  tertius  are  affected  varus  will  fol- 
low. Paralysis  of  the  calf  muscle  will  cause  calcaneus.  Paresis  or 
paralysis  of  the  entire  anterior  group  will  cause  equinus.  If  all  the 
muscles  are  paralyzed,  what  is  called  a  dangle  foot  is  the  result ;  the 
cold  atrophied  member  dangles  from  the  attenuated  limb  with  but 
little  tendency  to  deformity  unless  it  is  capable  of  use,  when  it  is  usu- 
ally forced  into  an  attitude  of  equino- varus  or  valgus. 

A  slight  degree  of  paralysis  may  cause  so  little  disability  that  it  may 
be  entirely  overlooked,  and  its  later  effect  in  causing  disability  or  de- 
formity may  not  attract  attention  for  many  years.  This  fact  has  been 
mentioned  in  the  etiology  of  the  contracted  foot. 

Differential  Diagnosis  Between  Congenital  and  Acquired  Deformity. — 
The  history  itself  usually  indicates  the  etiology,  for  deformity  of  the 
foot  at  birth  is  never  overlooked  by  the  mother.  Acquired  talipes  is 
practically  always  preceded  by  a  history  of  disease,  or  weakness,  or 
injury,  which  was  soon  followed  by  slight,  and  afterward  by  increasing 
deformity. 

In  paralytic  talipes  (anterior  poliomyelitis),  there  is  evidence  of 
paralysis  in  loss  of  function  of  certain  muscles,  as  shown  by  electrical 
stimulation   or  by  pricking  the  foot  with  a  pin  ;  later,  in  the  atrophy 


ACQUIRED   TALIPES  EQUINUS. 


611 


of  the  niuscles  and  often  in  the  evident  change  in  the  nutrition  and 
diminished  growth  of  the  limb. 

Only  in  neglected  and  extreme  cases  of  talipes  in  the  adolescent 
or  adult,  could  there  be  difficulty  in  distinguishing  between  the  ac- 
quired and  the  congenital  deformity.  In  rare  instances,  it  is  true, 
paralysis  may  be  present  at  birth,  due  to  intra-uterine  disease  or  to 
defect  in  the  nervous  apparatus.  In  such  cases  the  cause  of  the  par- 
alysis is  usually  apparent  (spina  bifida,  or  spastic  paralysis  associated 
with  defective  cerebral  development)  and  the  treatment  does  not  differ 
from  that  of  the  acquired  form. 

Acquired  Talipes  Equinus. 

In  well-marked  equinus,  the  foot  is  plantar  flexed  to  its  full  limit  and 
it  is  held  in  this  attitude  by  the  shortened  structures  on  the  posterior 
aspect  of  the  leg,  of  which  the  tendo  Achillis  is  the  most  important. 
The  patient  walks  upon  the  heads  of  the  metatarsal  bones,  the  toes  be- 

FiG.  432. 


Acquired  talipes  equiaus. 


ing  dorsi-flexed  to  accommodate  the  deformity.  The  arch  of  the  foot  is 
increased  and  the  tissues  of  the  sole,  particularly  the  plantar  fascia,  are 
contracted.  The  entire  foot  is  broadened  and  shortened,  the  breadth 
being  especially  increased  across  the  metatarsal  region.  (Fig.  385.) 
Corresponding  to  the  exaggerated  depth  of  the  arch,  the  dorsum  pro- 
jects, the  cuneiform  bones  are  prominent,  and  the  head  and  body  of  the 
displaced  astragalus  may  be  felt  beneath  the  skin  on  the  anterior  surface 
of  the  foot.  In  rare  instances,  and  in  those  cases  in  which  all  the'  an- 
terior muscles  are  paralyzed,  the  toes  may  be  plantar  flexed  so  that 
the  patient  walks  upon  their  dorsal  surface. 


612  DEFORMITIES  OF  THE  FOOT 

The  cavus  or  increased  depth  of  the  arch  is  due  primarily  to  the 
falling  downward  of  the  forefoot  at  the  medio-tarsal  joint,  and  in 
many  instances,  this  dropping  of  the  forefoot  is  in  great  degree  re- 
sponsible for  the  equiniis  ;  in  fact  the  os  calcis  is  rarely  plantar  flexed 
to  the  degree  commonly  found  in  the  ordinary  congenital  equinus. 

In  the  slighter  degrees  of  the  deformity  when  the  patient  still  walks 
upon  the  sole  of  the  foot,  the  toes  are  usually  dorsi-flexed,  an  attitude 
due,  apparently  to  the  over-action  of  the  extensor  longus  digitorum 
and  proprius  pollicis,  as  aids  in  dorsi-flexion.     (Fig.  432.) 

The  cases  of  slight  equinus  combined  with  cavus  have  been  de- 
scribed already  under  the  title  of  the  contracted  foot.  (Page  534.) 
The  exaggerated  arch  is  a  secondary  and  a  late  result  of  the  paralysis 
and  of  the  equinus  and  in  the  slight  degrees  of  deformity,  particularly 
in  the  early  stage  of  the  paralysis,  it  may  be  absent. 

Etiology. — Equinus  in  the  slighter  degrees  is  perhaps  the  most 
common  of  the  forms  of  talipes  acquired  in  later  life,  and  it  is  not 
at  all  infrequent  as  a  result  of  other  affections  than  anterior  poliomye- 
litis, although  as  has  been  stated,  this  is  by  far  the  most  important 
cause.  The  nerve  supply  of  the  anterior  muscles  of  the  foot  seems  par- 
ticularly susceptible,  and  toe-drop,  from  neuritis  of  various  types,  is 
not  at  all  uncommon.  As  a  sequel  of  infectious  diseases  it  has  been 
alluded  to  as  an  explanation  of  the  slight  forms  of  equinus  first  noticed 
after  recovery  from  such  aifections. 

Equinus  may  be  a  result  of  disease  of  cerebral  origin,  or  even  in 
rare  instances,  of  pseudo-hypertrophic  muscular  paralysis  or  locomotor 
ataxia.  It  is  sometimes  the  result  of  habitual  posture,  as  after  long 
confinement  to  the  bed  for  the  treatment  of  fracture  or  during  the 
treatment  of  hip  disease  by  apparatus  ;  or  the  contraction  may  be  an 
effect  of  voluntary  posture,  as  when  the  patient  habitually  walks  upon 
the  toes  because  of  a  short  leg.  It  is  a  very  common  result  of  neglected 
disease  at  the  ankle  joint,  and  it  may  be  a  result  of  direct  injury,  but 
as  of  paralysis,  so  of  these  less  frequent  causes  it  may  be  said,  that 
equinus  need  never  follow  if  the  foot  is  properly  supported. 

The  changes  in  the  internal  structure  of  the  foot  are  similar  to  those 
that  follow  other  forms  of  deformity  ;  the  tissues  on  the  long  side  are 
lengthened  and  attenuated,  while  those  on  the  short  side  become  con- 
tracted. The  bones  themselves  are  but  little  changed  in  gross  ap- 
pearance, but  the  articulating  surfaces  are  in  abnormal  relation  to  one 
another ;  for  example,  only  the  posterior  part  of  the  astragalus  may 
be  contained  within  the  malleoli  in  relation  to  the  tibia,  while  only 
the  lower  part  of  its  anterior  surface  articulates  with  the  scaphoid  bone. 
In  all  cases  of  equinus  there  is  a  strong  tendency  toward  lateral  de- 
viation to  varus  or  valgus.  This  is  especially  true  of  cases  of  par- 
alytic origin. 

Symptoms. — The  effects  of  the  deformity  vary.  If  the  leg  is  ac- 
tually shorter  than  its  fellow  so  that  the  lengthening  caused  by  the  ex- 
tension of  the  foot  is  no  more  than  a  sufficient  compensation  ;  and  if  the 
foot  is  firmly  fixed  in  the  deformed  position,  surprisingly  little   dis- 


TREATMENT  OF  ACQUIRED  EQUINUS.  613 

comfort  or  disability  may  be  experienced,  other  than  from  corns  or 
calluses  beneath  the  metatarsal  bones. 

If  the  leg  is  not  shorter,  the  additional  length  caused  by  the  equinus 
must  be  compensated  by  a  tilting  of  the  pelvis  and  lateral  deviation  of 
the  spine.  This  often  gives  rise  to  symptoms  of  discomfort  in  the 
lumbar  region.  The  gait  in  this  class  of  cases  is  always  awkward, 
giving  the  impression  as  of  stepping  over  an  obstacle. 

If  the  foot  is  not  fixed  in  the  attitude  of  equinns,  that  is,  if  it  hangs 
downward  when  it  is  lifted,  and  is  forced  into  a  fairly  normal  attitude 
by  the  weight  of  the  body,  the  gait  is  very  awkward  because  of  the  inse- 
curity and  because  of  the  exaggerated  flexion  of  the  knee  at  each  step, 
necessary  in  order  that  the  pendant  foot  may  not  drag  upon  the  ground. 

If  the  equinus  is  extreme,  the  limb  is  usually  flexed  at  the  knee  when 
in  use  ;  if  the  equinus  is  slight  the  strain  resulting  from  the  limita- 
tion of  dorsal  flexion  is  felt  at  the  knee,  and  in  childhood  at  least, 
there  is  often  a  well-marked  tendency  to  over-extension,  or  recurva- 
tura,  caused  by  the  eflbrt  to  place  the  sole  flat  on  the  ground. 

In  the  slight  forms  of  equinus,  discomfort  about  the  calf  is  experi- 
enced ;  the  limitation  of  dorsal  flexion  causes  a  rather  shortened  stride 
and  awkward  gait,  while  an  unguarded  step,  that  throws  a  sudden 
strain  upon  the  rigid  heel  cord,  is  felt  as  a  shock  and  strain  through 
the  leg  and  body.  Very  often  the  patient  complains  of  pain  about 
the  metatarsal  bones  (anterior  metatarsalgia),  and  if  the  equinus  is 
accompanied  by  a  slight  degree  of  valgus  symptoms  of  the  weak  foot 
may  be  present. 

The  prognosis  as  to  permanent  cure  depends  of  course  upon  the 
cause  of  the  deformity.  When  it  is  simply  the  result  of  posture  or  of 
the  ordinary  form  of  neuritis  and  the  like,  permanent  cure  may  be  ex- 
pected. In  many  of  the  cases  that  have  followed  anterior  poliomyelitis, 
recovery,  complete  or  partial,  of  the  original  injury  to  the  spinal  centers 
has  followed  ;  yet  although  voluntary  control  of  the  muscles  has  been 
regained  it  cannot  be  exercised  because  the  foot  is  held  in  the  distorted 
position  by  the  contracted  tissues.  In  such  instances  practical  cure 
may  be  predicted,  if  after  the  over-correction  of  deformity  suflicient 
time  is  allowed  for  the  over-stretched  and  atrophied  muscles  to  regain 
their  proper  length  and  volume. 

Treatment. — In  the  rare  cases  of  fixed  equinus  combined  with  a 
short  leg,  in  which  the  patient  suffers  no  symptoms,  it  is  well  to  allow 
the  position  to  remain,  a  shoe  being  so  built  that  the  heel  may  support 
a  part  of  the  weight.  In  the  more  extreme  cases  in  which  the  leg  is 
short  and  the  foot  is  atrophied,  an  extension  foot  attached  after  the 
manner  of  an  artificial  leg  may  be  worn  with  comfort  and  with  but 
little  evidence  of  deformity. 

In  the  ordinary  cases  whether  permanent  cure  is  expected  or  not,  the 
rule  holds  good  that  the  heel  should  bear  the  weight  of  the  body,  and 
that  the  range  of  dorsal  flexion  should  not  be  limited  when  the  calf 
muscle  retains  its  power.  If  the  nervous  apparatus  has  received  per- 
manent injury,  the  foot  must  be  supported  after  the  deformity  has  been 


614 


DEFORMITIES  OF  THE  FOOT. 


Fig.  433. 


rectified,  but  even  in  this  class,  the  gait  may  be  improved  and  the  discom- 
fort may  be  relieved  by  removing  the  restrictions  to  normal  motion. 

The  slight  degrees  of  equinus,  such  as  those  that  are  seen  soon  after 
the  onset  of  anterior  poliomyelitis,  may  be  overcome  by  simple  ma- 
nipulation and  retention  in  a  splint  or  in  a  plaster  bandage.  In  more 
resistant  cases,  in  older  subjects,  more  force  may  be  exerted  ;  for  ex- 
ample, the  patient  being  seated  extends  the  limb  ;  the  surgeon  stands 
in  front  of  him,  one  hand  holds  the  leg  firmly  at  the  ankle,  and  the 
other  grasps  the  foot ;  the  weight  of  the  body  is  then  thrown  against 

the  resistant  tissues  over  and  over  again 
with  as  much  force  as  is  consistent  with 
the  comfort  of  the  patient. 

The  Shaifer  extension  brace  is  also  a 
useful  appliance,  and  especially  so  be- 
cause it  may  be  employed  to  reduce  the 
accompanying  cavus  at  the  same  time. 

The  weight  of  the  body  as  a  means  of 
overcoming  equinus,  when  the  foot  is- 
held  in  its  proper  relation  to  the  leg  by  a 
brace,  has  already  been  mentioned,  but 
this  tedious  method  has  but  little  to 
recommend  it  in  ordinary  cases.  The 
elastic  tension  of  straps  and  bands  at- 
tached to  a  brace  or  to  the  foot  itself  by 
means  of  adhesive  plaster  is  of  some  ser- 
vice in  slight  cases,  but  by  far  the  most 
effective  method  is  the  immediate  reduc- 
tion of  the  deformity,  by  simple  forcible 
manipulation  under  anaesthesia,  or  by 
tenotomy  combined  with  forcible  manip- 
ulation, or  by  wrenching. 

Immediate  Correction  of  Deformity. — 
Attention  has  been  called  to  the  cavus  as  an  important  element  in 
equinus,  and  whenever  one  attempts  to  correct  the  equinus  deformity 
by  force,  the  exaggerated  arch  should  be  reduced  to  its  normal  depth, 
otherwise  the  foot  will  appear  stunted  and  deformed. 

One  of  the  most  effective  procedures  is  forcible  reduction  by  means 
of  the  Thomas  wrench.  (Fig.  417.)  The  resistant  bands  of  the 
plantar  fascia  are  first  divided  subcutaneously,  the  wrench  is  then  fixed 
to  the  foot  and  with  sudden  force,  exerted  against  the  resistant  tendo 
Achillis,  the  foot  may  be  straightened,  the  deep  ligaments  being  ruptured 
or  stretched  to  the  proper  degree.  The  tendo  Achillis  is  then  divided, 
a  wooden  foot  plate  is  placed  against  the  sole,  and  the  foot,  having  been 
dorsi-flexed,  is  fixed  by  a  plaster  of  Paris  bandage. 

As  the  patient  is  encouraged  to  walk  upon  the  foot  as  soon  as  pos- 
sible, the  weight  of  the  body  forcing  the  relaxed  tissues  against  the  un- 
yielding board  incorporated  in  the  plaster  completes  the  flattening  of 
the  arch.     In  many  of  these  cases,  tlie  knee  has  been  over-extended  by 


A  brace  to  prevent  foot-drop.      One 
upright  is  often  sufficient. 


THE  TONIC  EFFECT  OF  IMMEDIATE  COBBECTION. 


615. 


use  in  the  deformed  attitude,  so  that  the  habitual  flexion  necessary  io 
bring  the  dorsi-flexed  foot  upon  the  ground,  during  the  two  months  al- 
lowed for  the  complete  union  of  the  divided  tendon,  is  of  benefit,  as  it 
serves  to  correct  this  secondary  weakness  and  deformity. 

The  Tonic  Effect  of  Immediate  Correction. — The  impor- 
tance of  the  tonic  effect  of  immediate  relief  of  the  strain  of  the  de- 
formed position  upon  the  weak  anterior  group  of  muscles,  together 
with  the  complete  relaxation  of  the  over-stretched  tissues,  during  the 
long  rest  in  the  over-corrected  position,  is  not  generally  appreciated. 
Whenever  the  weakened  muscles,  after  paralysis,  show  by  tests  electri- 
cal or  otherwise,  that  they  have  recovered  their  power  in  part,  this 

Fig.  434. 


An  effective  and  inconspicuous  support  for  paralytic  toe-drop.  An  upright  of  light  tempered  steel, 
carefully  adjusted  to  the  inner  side  of  the  leg  and  ankle  provided  with  a  light  calf  band.  This  is 
strengthened  by  a  posterior  support  attached  to  the  upright.  The  lower  end  of  the  brace  is  arranged 
as  a  caliper  and  is  fitted  to  the  metal  disc  of  which  two  views  are  shown.  A  depression  is  cut  in  the 
heel  of  the  shoe  for  the  disc  as  is  shown  in  the  diagram.  Two  strong  elastic  tapes  are  sewed  to  the 
leather  of  the  shoe.  These  are  attached  to  the  studs  on  the  front  of  the  calf  band  and  thus  the  toe- 
drop  is  prevented.     (See  Fig.  435. ) 


treatment  should  be  that  of  selection.  The  application  of  electricity 
or  other  form  of  stimulation  to  muscles  that  are  unable  to  exercise 
their  function  because  of  contraction  of  the  opposing  tissues  is  absolutely 
useless.  Nor  is  any  form  of  artificial  stimulation  equal  to  that  of  the 
functional  use,  which  is  made  possible  by  the  removal  of  the  deformity 
and  by  the  employment  of  proper  support. 

Equinus,  more  often  than  any  other  deformity,  is  the  result  of  slight 
or  temporary  disability  of  the  anterior  group  of  muscles,  and  not  infre- 


616 


DEFORMITIES  OF  THE  FOOT. 


Fig.  435. 


quently  perfect  cure  seems  to  have  been  attained  when  the  plaster 
bandage  is  finally  removed,  usually  at  the  end  of  two  months  or  more. 
But  even  in  such  cases,  the  application  of  a  simple  support  to  hold 
the  foot  at  a  right  angle  with  the  leg  for  several  months,  is  of  ad- 
vantage. The  after-treatment  by  massage,  muscle-beating,  electricity, 
and  the  like,  combined  with  methodical  passive  movements  to  the  limit 
of  dorsal  flexion,  to  guard  against  recontraction  of  the  calf  muscle, 

should  be  continued  for  a  long 
time,  or  until  the  muscular  bal- 
ance has  been  regained. 

The  same  form  of  support  is 
necessary  in  cases  of  hopeless  pa- 
ralysis, to  hold  the  foot  at  a  right 
angle  with  the  leg.  The  common 
form  is  a  simple  steel  sole  plate  of 
sufficient  size  to  support  the  foot 
and  the  toes,  if  their  muscles  are 
paralyzed,  attached  to  a  light  up- 
right, provided  mth  a  calf-band. 
The  upright  is  usually  applied  on 
the  inner  side  of  the  leg,  where  it 
is  least  noticeable.  At  the  ankle, 
there  is  a  "  stop  joint,"  which 
allows  dorsi-flexion  but  prevents 
the  toe-drop.  This,  when  properly 
fitted,  can  be  placed  inside  the 
ordinary  shoe,  as  the  paralyzed 
foot  is  usually  somewhat  smaller 
than  its  fellow.  (Fig.  433.)  If  the 
toes  do  not  need  support,  the  up- 
right can  be  attached  to  the  out- 
side of  the  shoe  and  the  foot  plate 
may  be  dispensed  with.  Or,  the 
upright  may  be  concealed  by  in- 
troducing it  inside  the  shoe  to  a 
joint  sunk  in  the  heel ;  the  toe- 
drop  being  prevented  by  straps  passing  from  the  front  of  the  upper 
leather  of  the  shoe,  to  the  calf-band.     (Fig.  434.) 

Equinus,  due  to  posture  or  to  disease,  may  be  cured  by  simple  cor- 
rection of  the  deformity.  That  due  to  fracture,  when  the  deformity  is 
caused  by  displacement  of  the  bones,  may  be  treated  by  direct  opera- 
tion or  by  the  removal  of  a  cuneiform  section  from  the  anterior  surface 
of  the  tibia  above  the  ankle.     (See  tendon  grafting  and  arthrodesis.) 


The  same  appliance  (Fig.  434)  provided  witli  a 
foot  plate  of  metal  or  of  wood  as  sfiown  in  the  dia- 
gram. This  modification  is  useful  if  the  paralysis 
is  complete  or  if  the  foot  is  much  atrophied. 


Acquired  Talipes  Calcaneus. 

Acquired  talipes  calcaneus  is  much  less  frequent  than  equinus  and  it 
is  practically  always  of  paralytic  origin  (anterior  poliomyelitis),  although 


DEVELOPMENT  OF  DEFORMITY. 


617 


Fig.  436. 


cases  o^  calcaneus  following  injury  or  disease  or  distortion  of  the  limb 
are  occasionally  seen. 

There  are  several  varieties  or  grades  of  the  deformity.  In  the  early 
stage,  and  especially  if  all  the  muscles  of  the  posterior  group  have 
been  paralyzed,  the  foot  assumes  an  attitude  of  slight  dorsi-flexion  and 
the  range  of  plantar  flexion  is  gradually  lessened  by  secondary  contrac- 
tions. This  variety  resembles  closely  the  congenital  form.  (Fig.  386.) 
In  the  ordinary  and  typical  form  of  calcaneus,  when  fully  developed,  the 
patient  walks,  as  the  name  implies,  on  an  elongated  heel.  The  arch  of 
the  foot  is  much  increased  in  depth,  and  the  forefoot  is  atrophied  and 
useless. 

Development  of  Deformity. — The  development  of  the  de- 
formity is  somewhat  as  follows  :  When  the  tension  of  the  calf  muscle 
is  removed  the  os  calcis  gradually  assumes 
an  attitude  of  extreme  dorsi-flexion.  It  stands 
on  end  so  that  its  posterior  surface  becomes 
inferior.  The  posterior  projection  of  the  heel 
is  lost  and  it  lies  in  the  plane  of  the  atrophied 
calf.  The  change  in  the  position  of  the  os 
calcis  increases  the  distance  from  the  malleoli 
to  the  ground,  thus  calcaneus  though  in  less 
degree  than  equinus,  makes  the  leg  longer. 
The  turning  of  the  heel  on  end,  thus  lengthen- 
ing one  of  the  terminations  of  the  arch,  in- 
creases its  depth  and  at  the  same  time  shortens 
the  length  of  the  foot  so  that  cavus,  in  more 
marked  degree  than  with  equinus,  accompanies 
calcaneus.  The  cavus  is  a  later  complication 
of  nearly  all  cases  of  paralytic  calcaneus.  In 
many  instances  there  is  no  permanent  dorsi- 
flexion  or  elevation  of  the  forefoot,  although 
in  all,  the  range  of  plantar  flexion  is  limited. 
In  this  class  the  power  in  the  remaining 
muscles  of  the  posterior  group  is  probably 
sufficient  to  counteract  the  contraction  of  the 

dorsi-flexors.  Cavus  is  thus  a  direct  effect  of  the  displacement  of  the  os 
calcis.  If  the  entire  posterior  group  of  muscles  is  paralyzed,  while  the 
anterior  muscles  are  unaffected,  the  foot  will  be  somewhat  dorsi-flexed 
and  the  cavus  will  be  less  marked.  If  the  calf  muscle  only  (gastrocne- 
mius and  soleus)  is  paralyzed,  the  remaining  muscles  of  the  posterior 
group  will  counterbalance  the  dorsi-flexors,  and  at  the  same  time  in- 
crease the  cavus.  In  some  instances  the  calf  muscle  is  alone  affected, 
in  others  one  or  more  of  the  anterior  muscles  may  be  paralyzed  also,  in 
which  case  the  foot  is  usually  turned  toward  varus  or  valgus.  The 
changes  primarily  caused  by  the  paralysis  and  by  unopposed  muscular 
action  become  fixed  by  habitual  use,  and  by  secondary  adaptation  of  the 
tissues.  The  heel  only,  is  used  in  walking,  and  the  area  of  callus  which 
marks  the  weight-bearing  surface  becomes  much  enlarged,  while  the 


Paralytic  caloaneo-varus. 


618 


DEFORMITIES   OF  THE  FOOT. 


forefoot  and  toes  which  have  bat  little  functional  use  become  atrophied, 
a  mere  appendage  to  the  enlarged  heel.     (Fig.  439.) 

Symptoms. — The  gait  is  awkward  and  inelastic,  the  patient,  who  is 
as  it  were  "  ham-strung,"  stamps  along  upon  the  insecure  support  of 
the  heel  in  a  manner  which  is  easily  recognizable  by  one  familiar  with 
the  deformity.  The  changes  in  the  internal  structure  of  the  foot,  the 
inevitable  adaptations  to  the  deformity  do  not  call  for  especial  de- 
scription, the  disused  bones  atrophy  together  with  the  other  tissues, 
and  new  articulating  surfaces  form  to  accommodate  the  necessities  of 
functional  use. 

Treatment. — The  essence  of  successful  treatment  is  prevention. 
When  the  diagnosis  of  paralysis  of  the  calf  muscle  is  made,  one  may 
predict,  unless  recovery  takes  place,  a  deformity  such  as  has  been  de- 
scribed.    This   deformity  may  be  prevented  by  proper  support,  by 


Fig.  437 


Fig.  438. 


Judsou's  brace  for  calcaneous  deformity. 


massage  and  methodical  stretching  of  the  tissues  that  have  a  tendency 
to  contract.  The  form  of  brace  used  for  walking  and  support,  should 
be  provided  Avith  a  sole  plate,  upright  and  calf-band,  as  already  de- 
scribed in  the  treatment  of  paralytic  equinus.  If  motion  is  allowed 
at  the  ankle  it  should  be  in  plantar  flexion  only,  the  stop  being  the 
reverse  of  that  used  in  equinus,  or  as  this  form  of  check  entails  much 
strain  upon  the  brace,  the  joint  may  be  omitted  as  in  that  form  used 
by  Judson.  (Figs.  437,  438.)  Thus  the  strain,  removed  from-  the 
weakened  tissues,  is  borue  by  the  anterior  surface  of  the  leg.  Other 
forms  of  braces  are  sometimes  employed,  provided  with  elastic  bands 
to  supply  the  place  of  the  calf  muscle,  but  as  a  rule  the  improvement 
in  gait  hardly  compensates  for  the  trouble  in  adjustment  or  the  con- 
spicnousness  of  the  appliance. 

The  most  important  part  of  the  actual  deformity  of  calcaneus  is  the 


WILLETT'S  OPERATION  FOR  CALCANEUS. 


619 


cavus,  in  great  part  due  to  the  changed  position  of  the  os  calcis ;  and 
in  confirmed  cases  it  is  practically  impossible  to  reduce  this  except  in 
part,  because  the  loss  of  resistance  of  the  tendo  Achillis  takes  away 
the  point  of  fixation,  against  which  effective  force  can  be  exerted.  If 
the  deformity  is  not  marked,  the  foot  may  be  drawn  as  far  as  possible 
toward  equinus  and  fixed  in  a  plaster  bandage,  the  sole  part  being 
strengthened  by  the  insertion  of  a  thin  board.  Upon  this  the  patient 
may  walk,  the  heel  being  built  up  with  cork  wedges  to  make  the  sole 
level.  When  the  contraction  of  the  anterior  tissues  has  been  overcome, 
the  brace  is  applied  and  the  usual  treatment  of  manipulation  and  mas- 
sage is  continued. 

The    method    of    pro-  Fig.  439. 

longed  fixation  in  the  atti- 
tude of  equinus  by  means 
of  the  plaster  bandage  is 
often  very  efficacious  in 
childhood  and  cures  of  ap- 
parently hopeless  cases  by 
this  means  have  been  re- 
ported.^ 

Operative  Treatment. — 
In  more  extreme  cases  im- 
mediate reduction  of  the 
deformity  under  anaesthe- 
sia may  be  attempted. 
The  plantar  tissues,  more 
particularly  the  plantar 
fascia,  may  be  divided 
subcutaneously  or  by  open 
incision  and  by  forcible 
manipulation  or  wrench- 
ing the  sole  may  be  some- 
what lengthened  and  the 
heel  pushed  somewhat  up- 
ward and  backward,  so 
that  the  foot  may  be  fixed 
in  a  plaster  bandage  in  slight  plantar  flexion.  In  the  reduction  of  the 
deformity  one  must  not  force  the  forefoot  downward  as  this  would 
simply  increase  the  cavus,  but  whatever  correction  is  accomplished 
should  be  by  means  of  elevation  of  the  os  calcis  and  elongation  of  the 
tissues  of  the  sole  of  the  foot. 

In  some  instances  the  improved  position  of  the  os  calcis  may  be 
confirmed  by  shortening  the  tendo  Achillis,  as  first  performed  by  Wil- 
lett,  of  London.^ 

Willett's  Operation  for  Calcaneus. — A  Y-shaped  incision  about  two 
inches  in  length  is  made  through  the  tissues  down  to  the  tendon.     At 

'Gibney,  Trans.  Am.  Orth.  Ass'n,  Vol.  XIII.,  1900. 
2 St.  Bart's  Hosp.  Keports,  Vol.  XVI.,  1880,  p.  309. 


Paralytic  calcaneus,  showing  secondary  changes  in  contour. 


620 


DEFORMITIES  OF  THE  FOOT. 


Fig.  440. 


the  lower  or  vertical  part  of  the  iucisiou,  which  is  continued  down  to 
the  tuberosity  of  the  os  calcis,  the  tendon  is  dissected  free  from  the  sur- 
rounding parts.  It  is  then  divided  in  an  oblique  direction  from  within 
outwards,  and  downwards,  and  the  heel  having  been  pushed  upward  as 
far  as  possible,  the  divided  ends  are  overlapped  and  sutured  ;  the  flap 
of  skin  is  drawn  downwards  at  the  same  time,  so  that  the  Y-incision  is 
converted  into  the  shape  of  a  V.  According  to  Mr.  Willett's  original 
directions,  deep  sutures  are  passed  through  the  skin  flaps  and  through 
the  tendon  on  either  side,  so  that  all  the  tissues  are  united.     The  foot 

is  then  fixed  in  a  plaster  bandage,  and 
the  patient  is  allowed  to  walk  about 
wearing  a  high  heel  to  compensate  for 
the  elevation  of  the  sole. 

The  operation  is  of  value  in  those 
cases  in  which  some  power  remains  in 
the  calf  mascle,  which  is  thus  made 
serviceable. 

In  cases  of  complete  paralysis  the 
position  of  the  foot  may  be  temporarily 
improved,  but  unless  proper  support  is 
used  afterward  the  tissues  will  stretch 
under  the  strain  of  use  ;  thus  the  treat- 
ment should  always  be  supplemented  by 
a  brace  of  the  character  already  de- 
scribed.    (Fig.  438.) 

Astragalectomy  and  Backward  Dis- 
placement of  the  Foot. — In  cases  of  con- 
firmed calcaneus  or  calcaneus  combined 
with  lateral  deformity,  varus  or  valgus, 
removal  of  the  astragalus  may  be  in- 
dicated. This  operation  permits  the 
direct    contact  with  the  os  calcis,  thus 


Paralytic  varus  and  valgus.    (Gibney.) 


malleoli  to  be  brought  into 
increasing  the  security  of  the  foot. 

The  astragalus  may  be  removed  by  a  long,  curved,  external  incision 
passing  from  the  tendo  Achillis  just  below  the  outer  malleolus  to  the 
front  of  the  joint.  The  peronei  tendons  are  divided,  the  foot  is  dis- 
placed inward  and  the  astragalus  is  removed.  The  articulating  sur- 
faces of  the  leg  bones  and  of  the  os  calcis,  are  denuded  of  cartilage ; 
the  tendo  Achillis  is  shortened  and  to  it  the  peronei  tendons  are  at- 
tached if  the  muscles  are  active.  The  entire  foot  is  then  displaced 
backward  so  that  the  denuded  malleoli  overlap  the  anterior  extremity 
of  the  OS  calcis.  The  object  of  this  procedure  is  to  throw  the  weight 
of  the  body  upon  the  center  of  the  tarsus  ;  thus  the  deformity  is  reduced 
and  the  stability  of  the  foot  is  increased.  The  wound  is  closed  and 
the  foot  is  fixed  in  plaster  of  Paris.  As  soon  as  possible  the  patient 
uses  the  foot  in  standing  and  walking.  Ultimately  apparatus  may  be 
dispensed  with,  but  the  Judson  brace  may  be  used  for  a  time  with  ad- 
vantage.    This  operation  has  been  performed  in   many  instances  by 


Fig.  441. 


The  muscles  and  tendons  on  the  front  of  the 
leg.  (Testut.  )  From  Gerrish's  Anatomy. 


The  muscles  and  tendons  on  the  back  of  tlie 
leg.  (Testut. )  From  Gerrish's  Anatomy. 


622 


DEFORMITIES  OF  THE  FOOT. 


Fig.  443. 


the  author,  for  whom  it  is  now  the  treatment  of  choice  in  this  type  of 
deformity.  (Fig.  438.)  By  it  the  usefulness  of  the  foot  is  greatly 
increased  and  its  appearance  very  much  improved. 

Acquired  Calcaneo-Valgus  and  Calcaneo- Varus. 

In  many  cases,  the  foot  deformed  as  a  result  of  paralysis  of  the  calf 
muscle  is  in  addition  turned  in  a  lateral  direction,  so  that  the  weight 

of  the   body  falls  to  the  inner  or   outer 
side  of  its  center.     (Fig.  436.) 

Calcaneo-valgus  in  which  the  foot  is 
turned  outward  and  upward  so  that  the 
patient  walks  on  the  inner  side  of  the 
heel  or  even  on  the  inner  ankle  is  not  un- 
common. It  is  usually  a  result  of  more 
extensive  paralysis  than  simple  calcaneus. 
For  example,  all  the  muscles  about  "the 
foot  may  be  disabled  except  the  peronei, 
or  in  cases  of  a  milder  type  the  tibialis 
anticus  may  be  the  only  muscle  of  the 
front  of  the  foot  that  is  paralyzed. 

Treatment. — When  the  foot  inclines 
toward  calcaneo-valgus  it  is  difficult  to 
hold  it  in  proper  position.  The  usual 
method  is  to  apply  the  brace,  used  for 
ordinary  calcaneus,  with  the  upright  on 
the  outer  side  of  the  foot ;  the  ankle  and 
arch  are  then  held  against  it  by  means  of 
a  leather  strap.  Another  form  of  brace 
is  provided  with  an  upright  on  either 
side  of  the  leg,  the  outer  being  slightly 
longer  than  the  inner  so  that  the  sole  plate 
is  tilted  inward,  or  as  it  were  supinated; 
thus  the  weight  is  guided  towards  and 
balanced  on  the  outer  side  of  the  foot. 
It  must  be  borne  in  mind  that  other  mus- 
cles of  the  limb  are  often  paralyzed,  so 
that  the  deformity  of  the  foot  may  be  but 
a  part  of  more  general  distortion,  so  that 
the  foot  brace  is  often  combined  with  ap- 
paratus for  the  support  of  the  leg.  (Fig. 
314.) 

In  the  more  extreme  cases  the  deform- 
ity may  be  reduced,  and  the  stability  of  the  foot  may  be  increased  by 
the  removal  of  the  astragalus  in  the  manner  described. 

Calcaneo-varus  is  a  much  less  serious  affection,  since  the  foot  may  be 
more  easily  supported.  A  brace,  such  as  is  used  in  the  treatment  of 
ordinary  varus,  without  motion  at  the  ankle,  or  provided  with  a  reverse 
stop,  is  ordinarily  employed. 


Tendons  in  the  right  sole, 

From  Gerrish's  Anatomy 


(Testut.  ) 


ACQUIRED   TALIPES  EQUINO-VABUS.  623 

^  Acquired  Talipes  Equino-varus. 

Talipes  equino-varus  is,  in  the  acquired  as  in  the  congenital  form, 
the  most  common  of  the  deformities  of  the  foot.     (Fig.  440.) 

The  tendency  of  simple  equinus  is  usually  toward  varus,  because  in 
plantar  flexion  the  foot  is  slightly  adducted,  and  because  the  outer  side 
of  the  foot  is  shorter  than  the  inner  side  so  that  in  walking  with  the 
foot  extended  the  tendency  of  the  foot  is  to  turn  somewhat  inward. 
Equino-varus  is  usually  preceded  by  equinus,  and  the  etiology  of  the 
one  will  serve  for  the  other.     (Page  612.) 

In  certain  cases  the  varus  is  more  marked  than  the  equinus,  as  for 
example  when  the  abductors  of  the  foot  are  paralyzed  while  the  adduc- 
tors retain  their  power  ;  or  in  cases  of  direct  injury  as  in  fracture  at  the 
ankle ;  or  when  the  growth  of  the  tibia  has  been  arrested  as  the  result 
of  injury  or  disease. 

A  detailed  account  of  the  appearance  and  effect  of  the  deformity  is 
unnecessary.  In  the  early  stage  of  the  paralysis  it  may  be  reduced 
easily  ;  the  foot  must  then  be  supported  by  a  brace,  of  which  the  Taylor 
€lub  foot  apparatus  is  the  type.  (Fig.  410.)  During  the  night  the 
over-corrected  attitude  may  be  assured  by  a  strap  running  from  the  up- 
right to  the  sole  plate. 

If  the  deformity  is  fixed  it  should  be  reduced  and  over-corrected  by 
forcible  manipulation  under  anaesthesia.  Division  of  resistant  parts  is 
less  often  necessary  than  in  the  congenital  form,  but  it  may  be  re- 
quired in  neglected  cases.  The  over-corrected  position  should  be  re- 
tained until  time  has  been  allowed  for  the  recontraction  of  the  length- 
ened tissues ;  for  as  has  been  mentioned  in  the  treatment  of  equinus, 
over-correction  and  rest  is  by  far  the  most  effective  treatment  that  can 
be  applied  to  a  weak  or  paralyzed  part.  A  support  is  then  used  of  the 
character  indicated. 

Astragalectomy  and  cuneiform  osteotomy  are  rarely  indicated,  but 
the  latter  operation  is  sometimes  of  service  in  checking  the  tendency 
toward  recurrence  of  deformity,  which  is  more  marked  after  over-cor- 
rection in  the  paralytic  than  in  the  congenital  talipes. 

Acquired  talipes  equino-valgus  is  much  less  frequent  than  the  preced- 
ing deformity.  Simple  equino-valgus  is  usually  the  result  of  primary 
paralysis  of  the  tibialis  anticus,  the  most  powerful  of  the  dorsal  flexors ; 
thus  the  foot  is  drawn  somewhat  outward  when  dorsi-flexed,  while  the 
metatarsal  bone  of  the  great  toe,  having  lost  the  support  of  the  tibialis 
anticus  muscle,  falls  downward  and  is  drawn  outward  by  the  peroneus 
longus.  In  this  type  one's  attention  is  often  attracted  by  the  peculiar 
appearance  of  the  great  toe,  which  is  deformed  somewhat  like  a  ham- 
mer toe  by  the  over-action  of  the  extensor  longus  pollicis,  in  its  attempt 
to  take  the  place  of  the  tibialis  anticus.  The  equinus  is  usually  slight 
and  is  secondary  to  the  valgus.  Treatment  may  be  begun  by  placing 
the  foot  in  a  plaster  bandage  in  an  attitude  of  varus  and  allowing  the 
patient  to  walk  upon  it  until  the  tendency  toward  deformity  has  been 
overcome.     A  support  with  the  catch,  as  for  toe-drop,  is  applied  to  the 


624  DEFORMITIES  OF  THE  FOOT. 

shoe,  and  the  tendency  toward  valgus  is  checked  by  raising  the  inner 
border  of  the  sole  or  by  the  use  of  a  sole  plate,  as  in  the  treatment  of 
the  simple  weak  foot.     (Fig.  440.) 

Acquired  simple  talipes  valgus,  from  paralysis  of  the  tibialis  anti- 
cus  and  posticus  is  rare.  Talipes  valgus,  as  when  the  foot  is  dislo- 
cated outward,  in  cases  of  complete  paralysis  of  all  its  muscles,  may 
be  considered  as  a  variety  of  dangle  foot. 

Traumatic  valgus  and  ecLuino-valgus,  caused  by  fracture  at  the  ankle 
(Pott's  fracture)  may  be  treated  by  osteotomy  of  the  tibia  above  the 
ankle.  By  this  means  the  proper  relation  of  the  leg  to  the  foot  may 
be  restored  in  many  instances.  Equino-valgus  of  slight  degree  is  not 
uncommon  after  tuberculous  or  rheumatic  disease  at  the  ankle  or  at  the 
astragalo-scaphoid  joints.  This  is  practically  one  variety  of  the  weak 
foot. 

Talipes  valgus,  sometimes  called  spurious  valgus,  the  simple  weak 
or  flat  foot,  has  been  described  elsewhere  (Chapter  XX.). 

Talipes  caused  by  cerebral  disease,  whether  of  the  paraplegic  or  the 
hemiplegic  type,  is  almost  always  of  the  form  of  equino-varus  in  early 
childhood.  In  adolescence  the  deformity  may  be  equino-valgus  or 
even  calcaneo-valgus  if  there  is  extreme  flexion  at  the  knee.  The 
hemiplegic  form  of  talipes  is  much  more  rigid  and  unyielding  than  the 
paraplegic  type.  The  treatment  of  spastic  paralysis,  of  which  the  de- 
formity is  a  part,  is  discussed  elsewhere  (Chapter  XVIII.).  The 
deformity  must  be  corrected  by  the  ordinary  methods.  In  many  in- 
stances, when  the  contractions  are  not  marked,  mechanical  treatment 
is  unnecessary. 

Hysterical  equino-varus,  or  other  form  of  deformity,  is  not  espe- 
cially rare.  The  diagnosis  may  be  made  from  the  other  symptoms  of 
hysteria,  from  the  history  of  the  onset  and  duration  of  the  distortion, 
and  from  the  appearance  of  the  deformity,  which  is  evidently  merely 
an  assumed  posture.      (See  page  471.) 

Tendon  Transplantation  for  the  Relief  of  Paralytic  Talipes. 

When  one  or  more  of  the  muscles  are  paralyzed  the  unbalanced 
action  of  those  that  remain  tends  to  distort  the  foot.  The  object  of 
the  brace,  in  such  cases,  is  to  hold  the  foot  so  that  the  muscular  trac- 
tion, however  applied,  can  move  it  only  in  the  proper  directions. 
The  object  of  tendon  or  muscle  transplantation  is  to  utilize  the  mus- 
cular power  that  remains.  Thus  by  giving  an  active  muscle  a  new 
point  of  attachment  where  it  may  be  of  greatest  service  the  brace  may 
be  dispensed  with,  or  made  less  burdensome. 

Tendon  transplantation  is,  as  the  name  implies,  the  operation  of  at- 
taching the  tendon  of  a  living  to  that  of  a  paralyzed  muscle.  The 
first  operation  was  performed  by  Nicoladoni  in  1882,^  for  the  relief  of 
paralytic  calcaneus.  The  tendons  of  the  peroneus  longus  and  brevis 
were  divided  behind  the  external  malleolus,  and  the  proximal  ends 

1  Ai-cliiv  f.  Klin.  Chir.,  .'{,  27,  S.  660,  1882. 


TEND  ON  TBANSPLANTA  TION. 


625 


Fig.  444. 


united  to  the  distal  extremity  of  the  divided  teudo  Achillis.     The  re- 
sult is  said  to  have  been  satisfactoiy. 

The  first  operation  on  the  front  of  the  foot  was  performed  by  Parish/ 
of  New  York,  for  the  relief  of  paralytic  valgus,  by  sewing  the  tendon 
of  the  extensor  proprius  pollicis  to  that  of  the  paralyzed  tibialis  anticus, 
without  division  of  either  tendon.  In  more  recent  years  the  field  of  the 
operation  has  been  extended  by  Drobnik,  of  Posen,"  Goldthwait,^  of 
Boston,  and  others,  to  include  almost  every  possible  combination  of 
tendons  and  muscles. 

Tendon  transplantation  is  most  effective  from  the  curative  stand- 
point when  but  one  muscle  of  the  anterior  leg  group,  for  example  an 
adductor  or  abductor,  is  para- 
lyzed. The  most  common  form 
of  this  milder  type  is  paralysis 
of  the  tibialis  anticus.  As  this 
muscle  is  the  most  powerful 
dorsal  flexor  and  adductor  of 
the  foot  its  loss  is  followed  by 
secondary  equino-valgus.  In 
Parish' s  operation  the  tendon  of 
the  adjoining  extensor  proprius 
pollicis  was  simply  attached  to 
that  of  the  tibialis  anticus,  but 
as  the  extensor  of  the  great  toe 
is  a  very  weak  muscle,  its  power 
is  hardly  sufficient  for  the  double 
task.  A  more  efficient  proced- 
ure is  to  split  the  tendon  of  the 
paralyzed  muscle.  The  outer 
half  is  then  separated  from  its 
muscular  attachijient,  and  the 
distal  extremity  is  carried  across 
the  foot  and  is  sutured  to  all  the 
other  tendons.  The  proprius 
pollicis  is  then  attached  to  the 
inner  half.  In  cases  of  longer 
standing  and  more  marked  de- 
formity it  is  well  to  reduce  the 
power  of  the  abductors  by  cutting  the  tendon  of  the  peroneus  tertius 
from  its  insertion.  This  is  then  drawn  beneath  the  other  tendons 
and  is  attached  to  that  of  the  tibialis  anticus.  All  of  the  tendons  on 
the  front  of  the  ankle  may  then  be  sutured  to  one  another,  so  that  all 
may  act  as  direct  dorsal  flexors. 

If  varus  has  resulted  from  paralysis  of  the  peroneus  tertius  or 
brevis,  or  because  of  weakness  of  the  extensors  of  the  toes,  while  the 


Paralytic  equino-varus  before  operation. 
(See  Fig.  4-15.) 


IN.  Y.  Med.  Jour.,  Oct.  8,  1892. 

2Centb.  f.  Chir.,  N.  7,  July,  1894. 

3  Trans.  Am.  Orth.  Ass'n,  Vol.  VIII.,  1896. 


40 


626 


DEFORMITIES  OF  THE  FOOT. 


the  tibialis  anticus  retains  its  power  its  tendon  may  be  split,  the  outer 
half  having  been  separated  at  the  distal  end  may  be  passed  beneath  the 
other  tendons  to  be  attached  to  the  peroneus  tertius,  or  a  new  attach- 
ment to  the  tissues  on  the  outer  border  of  the  foot  may  be  made. 
(Fig.  445.) 

Every  variety  of  combination  has  been  employed.  The  tendon  of 
the  peroneus  longus  has  been  brought  across  the  foot  and  attached  to 
the  tibialis  anticus  for  the  relief  of  valgus.  The  tendons  of  the  flexor 
longus  pollicis  and  of  the  peroneus  brevis  have  been  attached  to  the 
tibialis  posticus  and  a  portion  of  the  inner  part  of  the  tendo  Achillis 
has  been  utilized  for  the  purpose  of  overcoming  the  same  deformity. 

Other  operations  on  the  back  of  the  leg  have  been  practically  that 
of  Nicoladini,  the  transplantation  of  the  two  peronei  muscles  into  the 

Fig.  445. 


Paralytic  equino-varus  cured  by  operation,  showing  power  of  dorsal  flexion  (one  half  of  the 
tendon  of  the  tibialus  anticus  attached  to  the  periosteum  of  the  outer  border  of  the  foot).  Operation 
July  19,  1898.  The  direct  union  of  tendons  to  periosteum  at  the  most  advantageous  point,  has  been 
urged  recently  by  Lange  (Ueber  Periostale  Schnenverplanzung  bei  Lahmung,  Munch,  med.  Woch., 
No.  15, 1900). 

tendo  Achillis ;  or,  as  modified  by  Goldthwait,  the  tendon  of  the  per- 
oneus longus  was  inserted  into  the  tendo  Achillis  and  the  brevis  was 
transplanted  into  that  of  the  flexor  longus  pollicis. 

The  operation  of  tendon  transplantation  should  not  be  performed 
until  the  recovery  from  the  paralysis  is  considered  impossible.  The 
incision  should  be  sufficiently  long  to  expose  the  tendon  and  the  mus- 
cular substance.  The  paralyzed  muscle  is  quite  different  in  color  from 
the  normal,  being  dull  reddish  yellow,  and  the  tendon  is  usually  dull 
white  in  place  of  the  silvery  glistening  color  of  the  normal  tendon. 
The  splitting  of  the  tendon  should  be  begun  high  up,  including,  in 
some  instances,  muscle  substance,  and  in  joining  the  splices,  as  much 


TENDON  TRANSPLANTATION 


627. 


surface  as  possible  of  each  splice  should  be  apposed  because  the  tendons 
do  not  readily  unite. 

Fine  silk  is  usually  employed  for  suturing.  The  tendon  sheaths  are, 
as  far  as  possible,  closed  by  fine  catgut  and  the  skin  incision  with  the 
same  material.  Before  the  operation  is  performed,  all  resistance  to 
normal  motion  should  be  overcome  by  force,  and  by  division  of  the 
contracted  parts,  if  necessary.  The  attachment  of  the  muscles  or  ten- 
dons should  be  made  while  the  foot  is  held  in  proper  position,  and  in 
many  instances,  it  is  well  to  cut  and  overlap  the  paralyzed  tendons  to 
aid  in  retaining  the  foot  in  the  improved  attitude. 

After  the  operation  is  completed,  the  foot  should  be  fixed  in  a  plas- 
ter bandage,  in  the  over-corrected  position,  for  several  weeks  or  more. 

Fig.  446. 


Talipes  equino-valgus  after  treatment  by  tendon  transplantation.  The  tendon  of  the  peroneus  ter- 
tius  was  attached  to  the  overlapped  and  shortened  tendon  of  the  tibialis  anticus.  All  the  tendons 
on  the  front  of  the  foot  were  then  united,  so  that  all  might  serve  as  dorsal  flexors. 

As  a  rule,  the  foot  should  be  supported  by  a  brace  until  it  is  evident  that 
the  union  of  the  parts  is  firm,  and  until  the  functional  result  is  assured. 
The  prognosis  will  depend  entirely  upon  the  character  of  the  par- 
alysis. If  the  tibialis  anticus  is  alone  affected,  sufficient  power  may 
be  borrowed  from  the  other  muscles  to  lift  the  foot  at  least  suificiently 
to  prevent  awkwardness  of  gait,  and  to  restrain  deformity.  Even 
more  favorable  is  the  prospect  for  the  relief  of  varus,  caused  by  weak- 
ness of  the  abductors,  but  it  is  impossible  for  weak  muscles  like  the 
peronei,  to  supply  the  place  of  the  great  calf  muscle  or  even  to  restrain 
the  deformity  of  calcaneus.  The  power  obtained  from  the  peronei 
however,  which  has  become  useless  and  even  harmful  because  it  draws 
the  foot  into  deformity,  may  be   sufficient  to  hold  the  heel  in  proper 


628  DEFORMITIES  OF  THE  FOOT. 

position  and  at  least  to  aid  the  brace  in  retaining  the  foot  in  a  normal 
attitude.  The  origin  and  insertion  of  the  muscles,  are  shown  in  Figs. 
340-350  inclusive. 

The  relative  strength  of  the  muscles,  as  well  as  their  function,  should 
be  considered  in  selecting  grafts,  and  in  prognosis  also.  According  to 
Fick,  it  is  as  follows,  in  kilogrammeters  (see  page  503)  : 

Back  of  the  Leg. 

The  calf  muscle — gastrocnemius  and  soleus 8.21 

Tibialis  posticus 0.40 

Peroneus  longus 0. 44 

Flexor  com.  digitorum 0.37 

Flexor  longus  pollicis 0.82 

10.24 
Front  of  the  Leg. 

Tibialis  anticus 1.61 

Extensor  proprius  pollicis 0. 39 

Extensor  longus  digitorum 0. 72 

Peroneus  bre vis 0.31 

Peroneus  tertius 0. 20 

The  importance  of  the  calf  muscle  on  the  back,  and  tibialis  anticus 
on  the  front  of  the  leg,  is  apparent.  The  former  is  nearly  four  times 
as  strong  as  the  combined  posterior  group,  the  latter  equal  to  all  the 
others  on  the  front  of  the  leg. 

It  has  been  claimed  that  the  transplanted  muscle  may  become  hyper- 
trophied  and  that  its  strength  may  increase  sufficiently  to  carry  out  its 
new  function,  but  this  is  somewhat  doubtful. 

Direct  transplantation  of  muscles  on  the  same  principle  as  tendon- 
grafting,  has  also  been  performed  by  Drobnik,  Goldthwait  and  others  ; 
for  example,  the  sartorius,  the  gracilis,  or  the  tensor  vaginse  femoris 
may  be  transplanted  into  the  substance  of  the  quadriceps  extensor 
muscle.  Drobnik  has  suggested  the  possibility  of  regenerating  the 
paralyzed  muscle  by  thus  engrafting  a  portion  of  one  that  is  still 
active,  but  this  is  a  possible  rather  than  a  probable  outcome.^ 

The  principle  of  the  operation  applies  of  course  to  other  parts  of  the 
body  as  well,  but  the  opportunities  for  its  application  are  far  less  fre- 
quent than  in  the  lower  extremities.  The  transplantation  of  certain 
of  the  over-active  flexor  muscles  to  the  extensor  aspect  of  the  limb  is 
sometimes  of  service  in  overcoming  the  deformities  of  spastic  paraly- 
sis. The  operation  may  be  of  especial  service  in  the  treatment  of  de- 
formity of  the  hand  in  hemiplegia.     (See  page  464.) 

The  operation  of  tendon  transplantation  is  often  indicated,  as  is  illus- 
trated by  the  fact  that  it  has  been  employed  in  fifty-five  instances  at  the 
Hospital  for  Ruptured  and  Crippled  during  the  past  year.  The  author 
has  always  employed  long  incisions  to  thoroughly  expose  the  muscles 
and  fine  silk  for  tendon  sutures.  Tendon  transplantation  has  been 
combined,  as  a  rule,  with  tendon  shortening,  and  in  many  instances  all 

1  It  is  impossible  to  formulate  rules  for  tendon  transplantation.  The  fii-st  essential 
is  exact  knowledge  of  the  degree  and  distribution  of  the  paral.ysis  in  the  case  to  be 
treated,  and  of  the  funcHon  and  strength  of  the  muscles  that  remain.  One  may  then 
decide  how  this  power  may  be  best  applied,  in  order  to  balance  the  foot  and  to  over- 
come deformity. 


ABTHEODESIS. 


629 


Fig.  447. 


the  tendons  on  the  front  of  the  foot  have  been  sutured  to  one  another, 
so  that  all  the  power  might  be  utilized  for  dorsi-flexion.  In  certain 
cases  the  transplanted  tendon  may  be  united  directly  to  the  periosteum 
on  the  inner  or  on  the  outer  side  of  the  foot,  instead  of  to  the  para- 
lyzed tendon.  Tendon  transplantation  may  be  combined  also  with  other 
operations,  such  as  astragalectomy,  cuneiform  osteotomy  and  the  like. 

Texdox  Splicixg. — Division  and 
over-lapping  of  the  tendons  of  para- 
lyzed muscles  may  be  employed  with 
advantage  in  certain  instances.  For 
example,  in  complete  paralysis  of  all 
the  dorsal  flexors  of  the  foot,  each  ten- 
don may  be  shortened  and  attached  to 
the  anterior  ligament,  thus  the  toe-drop 
may  be  remedied,  or  reduced  to  such 
an  extent  that  the  deformity  may  in- 
terfere but  slightly  with  locomotion. 
As  a  rule  however  apparatus  must  be 
employed  to  prevent  a  recurrence  of 
the  deformity.^ 

Arthrodesis. 

Arthrodesis,  the  removal  of  the  car- 
tilaginous surfaces  of  adjoining  bones 
and  thus  inducing  anchylosis  for  the 
relief  of  paralytic  deformities  of  the 
foot,  was  first  performed  by  Albert, 
of  Vienna,  in  1878.  As  applied  to 
the  foot,  it  is  usually  limited  to  those 
cases  in  which  practically  no  muscular 
power  remains,  the  so-called  dangle  foot. 

It  may  be  of  service  also  in  cases  of  less  disability  as  in  equinus  or  cal- 
caneus, when  the  patient  is  unable  to  provide  himself  with  apparatus. 

The  operation  consists  in  opening  the  joint  and  removing  the  carti- 
lage from  the  apposed  surfaces  of  the  bones,  then  sewing  or  nailing 
them  to  one  another,  or  simply  fixing  the  parts  in  a  plaster  bandage 
until  union  has  taken  place.  If  the  case  is  one  of  simple  calcaneus  or 
equinus,  without  lateral  deviation,  the  operation  may  be  limited  to  the 
ankle  joint  which  may  be  opened  from  the  back  or  front  or  side,  as 
seems  preferable.  The  cartilage  is  usually  removed  with  a  sharp  spoon, 
and  at  the  same  time  the  relaxed  tissues  may  be  shortened  after  the 
Willett  method,  if  the  deformitv  be  calcaneus  ;  or  the  tendons  on  the 


Alirace  with  a  "  Jimited  "  joint  allow- 
ing slight  motion  at  the  ankle  for  paral- 
ysis or  weakness. 


'  Besides  those  mentioned  in  the  text,  the  following  are  the  more  important  articles 
on  the  suhject  of  tendon  transplantation  :  Hacker,  Wiener  Med.  Presse,  1886.  Phocas, 
Eevue  d'Orthopedie,  T.  4,  189.3.  Winkleman,  Zeits.  fiir  Cliir.,  Ed.  39,  S.  109. 
Milleken,  N.  Y.  Medical  Eecord,  Dec,  1895.  Ghillini,  Zeits.  fiir  Orth.  Chir.,  Bd.  4, 
1896.  F.  Franke,  Arcliiv fiir  Klin.  Chir.,  Bd.  52,  H.  1  ;  Bd.  57.  Eulenbiira-,  Deutsche 
med.  Wochens.,  N.  14,  1898.  Goelet,  Zeits.  fiir  Orth.  Cliir.,  Bd.  7,  II.  1,  1899. 
Hofla,  Berlin,  klin.  AVochens.,  X.  30,  1899. 


630  DEFORMITIES   OF  THE  FOOT. 

front  of  the  foot  may  be  similarly  shortened  with  the  aim  of  lifting  the 
toes  to  the  proper  level,  if  they  are  depressed.  If,  as  in  many  in- 
stances, the  deformity  is  equinuo-varus  or  valgus,  the  simple  fixation 
at  the  ankle  joint  will  be  insufficient  and  it  must  be  supplemented  by 
arthrodesis  of  one  or  more  of  the  anterior  articulations. 

In  cases  of  calcaneo-valgus,  the  removal  of  the  astragalus  will  be 
found  to  be  a  useful  operation,  since  it  improves  the  stability  of  the 
joint,  and  the  limitation  of  motion  is  usually  sufficient  to  prevent  de- 
formity. If  the  astragalus  is  not  removed,  the  operation  must  include 
the  fixation  of  the  astragalo-scaphoid,  and  the  medio-tarsal  as  well  as 
of  the  ankle  joint,  and,  if  toe-drop  is  extreme,  of  the  tarsal  joints  also. 

The  method  of  operating  depends  upon  the  deformity.  In  simple 
arthrodesis  of  the  ankle  joint  for  toe-drop,  the  joint  may  be  opened  by 
a  perpendicular  incision  over  the  front  of  the  ankle. 

For  calcaneus,  the  posterior  incision  may  be  employed,  if  it  is  in- 
tended to  shorten  the  tissues  after  the  Willett  method  in  connection 
with  the  arthrodesis. 

Both  the  ankle  and  the  calcaneo-astragaloid  joints  can  be  opened 
from  the  back,  although  the  upper  one  may  be  more  easily  reached 
from  the  front.  If  it  is  necessary  to  fix  the  medio-tarsal  joint  as  well 
as  the  ankle  joint,  a  curved  incision  may  be  made  beneath  the  inner 
malleolus  to  the  middle  of  the  foot ;  or  if  the  foot  is  in  varus,  the  incision 
may  be  made  on  the  outer  side.  The  cartilaginous  surfaces  of  the 
bones  must  be  completely  removed  if  firm  anchylosis  is  to  be  obtained. 
The  parts  may  be  fixed  with  sutures  or  nails,  l3ut  this  is  unnecessary 
if  accurate  opposition  can  be  obtained.  The  foot  is  fixed  by  means  of  a 
plaster  bandage  in  the  line  of  the  leg,  slightly  dorsi-flexed,  and  as  soon 
as  possible  the  patient  is  encouraged  to  use  the  part. 

The  improvement  in  the  gait,  obtained  by  the  rectification  of  de- 
formity and  by  fixation  of  the  foot,  is  often  very  marked,  and  in  many 
instances  support  may  be  discarded.  But,  in  early  childhood  at  least, 
the  patients  should,  if  possible,  be  kept  under  observation,  in  order  that 
support  may  be  applied  if  the  deformity  shows  a  tendency  to  recur. 

Arthrodesis  is  also  performed  at  the  knee  and  at  other  joints  for 
the  purpose  of  fixing  the  part  in  a  useful  attitude.  In  certain  in- 
stances, the  operation  is  indicated.  It  is,  of  course,  limited  to  cases  of 
hopeless  paralysis  and  it  is  more  suitable  to  the  older  than  the  younger 
class  of  patients.^  , 

'  The  move  important  articles  on  arthrodesis  are  the  following  :  Bidone,  Archiv 
di  Ortoped.,  Fase.  6,  1894.  Samter,  Centb.  fur  Chir.,  1895,  N.  21,  S.  497.  Karewski, 
Centb.  fur  Chir.,  1895,  N.  25,  S.  593.  Jones,  The  international  Medical  Annual, 
1895,  p.  407.  Karasiewicz,  Inaug.  Diss.  Konigsberg,  1894.  Broca,  Eevue  d'Ortho- 
pMie,  Nov.,  1894.  Roersch,  Revue  de  Chir.,  1892,  No.  6.  Kirmisson,  Revue  d'Or- 
thopedie,  N.  2,  1896.     Popper,  Wiener  klin.  Rundschau,  N.  20,  1900. 


INDEX. 


ABSCESS  in  extra-articular  tuberculous 
joint  disease,  199 
in  hip  disease,  see  Abscess  in  Tuber- 
culous Disease  Hip  Joint,  255 
pelvic,  in  lumbar  Pott's  disease,  40 
in  Pott's  disease,  87 

in  different  regions,  88 
treatment  of,  89 
in  sacro-iliac  disease,  119 
secondary,  in   tuberculous  joint  dis- 
ease, 200 
in  thoracic  region,  49 
in  tuberculous  disease  of  ankle  joint, 
334 
of  hip  joint,  285 

frequency  of,  285 
significance  of,  286 
treatment  of,  287 
by    aspiration, 

288  _  . 
by  incision,  288 
by      injection, 
288 
of  knee  joint,  318 

statistics  of,  318 
treatment  of,  318 
by    aspiration, 

318 
by  incision,  318 
of  shoulder  joint,  350 
Absent  patella,  329 
Achillo-bursitis,  544 

etiology  of,  545 
pathology  of,  545 
symptoms  of,  545 
treatment  of,  546 
brace  in,  546 
operative,  546 
posterior,  547 

symptoms  of,  547 
treatment  of,  547 
Achillodynia,  see  Achillo-bursitis,  544 
Achondroplasia,  see  Foetal  Rhachitis,  367 
Acquired  genu  recurvatum,  332 
Acquired  talipes,  609 
calcaneus,  616 

astragal ectomy  for,  620 
development  of  deformity  of, 

617 
symptoms  of,  618 
treatment  of,  618 

operative,  619 
Willett's  operation  for,   619 
development  of  deformity  in,  609 


Acquired  talipes,  differential  diagnosis  in, 
610 
equino-valgus,  623 

treatment  of,  623 

equino-varus,  623 
treatment  of,  623 

cuneiform      osteot- 
omy in,  623 
equinus,  611 

etiology  of,  612 
immediate  correction  of  de- 
formity of,  614 

Thomas    wrench 
for,  614 
tonic  effect  of,  615 
prognosis,  613 
symptoms  of,  612 
treatment  of,  613 

Shaffer  extension  brace 
in,  614 
etiology  of,  609 
Acquired  torticollis,  479 
Acromegalia,  371 
diagnosis  of,  371 
symptoms  of,  372 
Actinomycosis  of  spine   108 
Acute  torticollis,  479 
Amputations,  spontaneous,  congenital,  608 
Anchylosis,  218 
etiology,  218 
pathology,  218 
prevention  of,  219 
treatment  of,  219 

by  forcible  correction,  220 
operative  exploration  in,  220 
by  passive  motion,  220 
Ankle  joint,  tuberculous  disease  of,  334 
sprain  of,  342 
chronic,  344 

treatment,   345 
symptoms,  342 
treatment,  343 

by  plaster  bandage,  343 
by  plaster  strapping,  343 
Anterior  bow  leg,  428 

symptoms  of,  429 
treatment,  429 
Anterior  curvature  of  tibia,  see  Anterior 

Bow  Leg,  428 
Anterior  dislocation  of  hip,  380 
Anterior   displacement  of   the  tibia,   see 

Congenital  Genu  Recurvatum,  328 
Anterior  metatarsalgia,  538 

complications  of,  542 


632 


INDEX. 


Anterior  metatarsalgia,  etiology  of,  538 
influence  of  shoe  in  causing  dis- 
ability and  pain  in,  541 
pathology  of,  538 
treatment  of,  542 
brace  for,  543 
support  in,  543 
Anterior  poliomyelitis,  acute,  440 

causes  of  deformity  of,  445 
deformities     of    upper    ex- 
tremity in,  447 
of  neck  in,  447 
of  trunk  in,  448 
secondary  in,  449  I 

diagnosis  of,  443  | 

differential,  443,  444 
etiology,  441 
pathology,  440 
prognosis,  444 
retardation  of  growth  in,  449 
statistics  of,  441 

tables  of,  441,  442 
symptoms  of,  442 
treatment  of,  450 

mechanical      principles 

of,  450 
prevention  of  deformity 
in,  450 
arthrodesis  in,  456,  see  Talipes 
osteotomy  in,  457 
paralysis  in,  444 

of  anterior   muscles  of  leg, 
in  450,  see  Talipes 
paralysis  of  arm  in,  455 
electrical  test  for,  445 
muscles  of  hip  in,  454 
of  posterior  muscles  of  leg 

in,  451 
of  thigh  muscles  in,  451 
paralytic  scoliosis  in,  454 
reduction  of  deformity  of,  455 

by  braces,  456 
tendon  transplantation  in,  456 
treatment,  operative,  455,  457 
Arborescent  synovial  tuberculosis,  201 
Arthectomy  in  tuberculous  disease  of  knee 
joint,  319 
advantage  of,  319 
results  of,  319 

statistics  of,  31 9 
table  of  short- 
ening, 320 
Arthritis,  acute,  of  infancy,  211 

deformans,  see  Osteo-arthritis,  212 
folloM'ing  infectious  disease,  210 

operative     intervention 

in,  211 
treatment  of,  211 
typhoid  fever,  211 

statistics  of,  211 
gonorrhoeal,  208 

statistics  of,  208 
symptoms  of,  208 
treatment  of,  210 
varieties  of,  209 
infectious,  of  knee  joint,  325 


Arthritis,  infectious,  treatment  of,  325 
puerperal,  210 

rheumatoid,  of  knee  joint,  325 
of  spine.  111 

chronic  rheumatoid,  113 
treatment  of,  111 
tuberculous,  acute,  212 
Arthrodesis,  629 

description  of  operation,  629 
for  toe  drop,  630 

in  treatment  of  anterior  poliomyelitis, 
456,  see  Talipes 
Astragalectomv  in  treatment  of  calcaneus, 
620 
in  treatment  of  club  foot,  598 
Asymmetrical  development,  189 
Ataxia,  hereditary,  468 

symptoms  of,  469 
Atrophy,  muscular  progressive,  466 

BACK  knee,  see  Genu  Eecurvatum,  Ac- 
quired, 332 
lower  part  of,  pain  in,  116 

treatment  of,  116 
Bands,  constricting,  congenital,  608 
Bending  of  neck  of  femur,  see  Coxa  Vara, 

392 
Bier"  s  treatment,  see  Venous  Stasis,  205 
Bilateral  coxa  vara,  397 

dislocation  of  hip,  379 
Billroth  splint  in  treatment  of  tuberculous 

disease  of  knee  joint,  313 
Bow  leg,  see  Genu  Varum,  405,  423 

anterior,  428 
Braces  in  treatment  of  lateral  curvature 

of  spine,  148,  176 
Bradford  frame,  60,  271 

in  treatment  of  rhachitis,  366 
Burs*  in  popliteal  region,  326 
Bursitis,  chronic,  at  shoulder,  359 
prepatellar,  325 
pretibial,  326 

pALCANEO-BUESITIS,  547 

l_'  symptoms  of,  547 

treatment  of,  547 
Caliper  brace  in  treatment  of  tuberculous 
disease  of  knee  joint,  317 
description  of,  317 
Calot's  operation,  101-103 
Campbell  brace,  in  treatment  displacement 

semilunar  carfilage  in  knee,  327 
Caput  quadratum,  363 
Cerebral  paralysis  of  childhood,  459 
Cervical  opisthotonos,  491 
Charcot's  disease,  217 
diagnosis,  217 
distribution,  217 
pathology,  217 
I  statistics  of,  217 

symptoms,  217 
treatment,  218 
Chest,  circumference  of,  table  of,  190 
deformities  of,  186 
1  flat,  186 

I  treatment  of,  186 


INDEX. 


633 


Chest,  funnel,  187 
pigeon,  186 

treatment  of,  187 
Chondrodystrophia,  see  Foetal  Rhacliitis, 

367 
Clavicle,  absence  or  defect  of,  188 
acquired  luxation  of,  188 
treatment  of,  188 
Club  band,  434 

etiology,  434 
statistics  of,  435 
treatment  of,  436 
operative,  436 
Club  foot,  astragalectomv  in  treatment  of, 
598 
confirmed,     correction     of,     method 

Julius  Wolff;  593 
congenital,  anatomy  of,  569 
symptoms  of,  572 
treatment  of,  572 
cuneiform    osteotomy    in    treat- 
ment of,  599 
division  of  the  tendo  Achillis  in 
treatment  of,  592 
forcible  correction  of  deformity  of,  by 
osteoclasts,  596 
by   Phelps'    opera- 
tion, 596 
bv  Thomas  method, 
"  595 
manual  correction  of,  585 
hysterical,  470 

differential  diagnosis  of,  471 
infantile,  principles  of  treatment  of, 
573 
rectification  of  deformity  of, 

574 
treatment  of,  mechanical,  574 
bv  plaster  bandage, 

^575 
by      splints        and 
braces,  577 
retention  brace  in,  581 
tenotomy  in,  579 
malleotomy  in  treatment  of,  591 
mechanical    rectification   of   de- 
formity of,  600 
Jiidson    brace   for, 
600 
osteotomy  in  treatment  of,  598 

secondary  treatment  of,  600 
rapid  correction  of  deformity  of,  585 
subcutaneous  tenotomy  in  treat- 
ment of,  591 
treatment    of,     division    of     plantar 
fascia  in,  593 
of  tibialis  anticus  in,  593 
posticus  in,  593 
Congenital   absence   of    fibula   associated 
with    talipes 
equino  -  val- 
gus, 606 
etiology  of,  607 
statistics  of,  606 
treatment     of, 
607 


Congenital  absence  of  tibia  associated  with 
talipes    var- 
us, 607 
prognosis      of, 

607  _ 
statistics  of,  607 
treatment     of, 
607 
club  foot,  569 
contraction  of  fingers,  437 
treatment  of,  437 
at  knee,  332 
deficiency  and  hypertrophy,  607 
deformities  of  elbow,  433 

at  wrist,  434 
dislocation  of  hip,  see  Hip  Joint,  Con- 
genital Dislocation  of,  373 ' 
of  shoulder,  430 

treatment  of,  430 
displacement  of  patella,  329 
elevation  of  scapula,  185 
etiology  of,  185 
treatment  of,  186 
genu  recurvatum,  328 
hallux  varus,  see  Pigeon  Toe,  551 
lateral  curvature  of  spine,  135 
oedema  of  feet,  608 
talipes  calcaneus,  604 

statistics  of,  604 
treatment  of,  604 
equinus,  604 

statistics  of,  604 
valgus,  605 

statistics  of,  605 
varus,  603 
torticollis,  475 
Constricting  bands,  congenital,  608 
Contracted  foot,  see  Hollow  Foot,  534 
Contraction  of  fingers,  congenital,  437 
treatment  of,  437 
confirmed  club  foot,   method  Julius 
Wolff;  593 
Coxa  vara,  392 

bilateral,  397 
diagnosis  of,  398 
etiology  of,  393 
mechanical  effects  of,  394 

predisposition  to  deformity 
of,  393 
pathology  of,  393 
physical  effects  of,  396 
statistics  of,  394 
table  of,  395 
symptoms  of,  394 
traumatic,  402 

diagnosis  of,  402 
treatment  of,  402 
treatment  of,  399 

apparatus  in,  400 
operative,  400 

cuneiforii?       osteotomy, 

401 
linear  osteotomy,  400 
unilateral,  symptoms  of,  396 
Craniotabes,  363 
Cretinism  allied  to  foetal  rhachitis,  367 


634 


INDEX. 


Cubitus  valgus,  433 
varus,  433 

Cuneiform  osteotomy,  in  treatment  of  an- 
terior bow  leg,  429 
of  club  foot,  599 
of  coxa  vara,  401 
of  genu  valgum,  422 
of  hallux  valgus,  554 
of  talipes,  599 

Cysts  in  popliteal  region,  326 

DEPRESSIOX  of  neck   of   femur,    see 
Coxa  Vara,  392 
Development,  asymmetrical,  189 

normal,  tables  of,  190 
Diagnosis  of  Achillo-bursitis,  545 
of  acquired  talipes,  610 
of  acromegalia,  371 
of  actinomycosis  of  spine,  108 
of  anterior  metatarsalgia,  538 
of  acute  epiphysitis  at  hip,  301 

anterior  poliomyelitis,  443 

torticollis,  482 
of  calcaneo-bursitis,  547 
of  Charcot's  disease,  217 
of  congenital  dislocation  of  hip  joint, 
380 

elevation  of  scapula,  183 

paralysis,  461 
of  coxa  vara,  398 

unilateral,  397 
bilateral,  398 
of  displacement  of  peronei  tendons, 

555 
of  erythromelalgia,  548 
of  fractui'e  of  neck  of  femur,  402 
of  functional  affections  of  joints,  472 
of  gluteal  bursitis,  302 
of  gonorrhosal  arthritis,  209 
of  hallux  rigidus,  549 
of  hollow  foot,  535 
of  hysterical  club  foot,  470 

hip,  469 
of  injury  of  spine,  108 
of  lateral  curvature  of  spine,  141 
of  malignant  disease  of  spine,  107 
of  obstetrical  paralysis,  431 
of  osteo-arthritis,  215 

arthropathy,  371 
of  osteitis  deformans,  371 
of  periarthritis  of  shoulder,  358 
of  poliomyelitis,  anterior,  442 
of  Pott's  paraplegia,  96 
of  pseudo-hypertrophic  muscular  pa- 
ralysis, 468 
of  rhachitic  spine,  109 
of  rhachitis,  365 
of  sacro-iliac  disease,  118 
of  sciatic  scoliosis,  117 
of  spondylitis  deformans  of  spine,  113 
of  syphilis  of  spine,, 107 
of  torticollis,  482 
of  traumatic  coxa  vara,  402 
of  tuberculous  disease  ankle  joint,  339 
elbow  joint,  351 
hip  joint,  244 


Diagnosis  of  tuberculous  knee  joint,  310 
shoulder  joint,  350 
of  spine,  4l,  50,  54 
sub-astragaloid  joint,  339 
of  tarsus,  341 
of  typhoid  spine,  110 
of  weak  foot,  514 
Dislocation   of  hip,   congenital,  see  Hip 
Joint,    Congenital    Dislocation  of 
373 
of  shoulder,  congenital,  430 
treatment  of,  430 
recurrent,  432 

treatment  of,  432 
operative,  433 
Displacement  of  peronei  tendons,  555 

treatment  of,  556 
"Double  joints,"  363 
Dupuytren's  contraction,  438 
etiology  of,  439 
pathology  of,  439 
symptoms  of,  439 
treatment  of,  439 
Dystrophy,  muscular,  467 

ELBOW,  congenital  deformities  of,  433 
excision  of,  in  tuberculous  disease  of, 

353 
joint,  tuberculous  disease  of,  351 
Elongation  ligamentum  patellse,  331 
Epiphysis   of   head   of  femur,   traumatic 

separation  of,  404 
Epiphysitis,  acute,  211 

distribution  of,  211 
etiology  of,  211 
prognosis,  212 
statistics  of,  211 
symptoms  of,  212 
treatment  of,  212 
Equino-varus,  hysterical,  624 
Erythromelalgia,  548 
Exercise  in  treatment  of  lateral  curvature 

of  spine,  151,  164 
Exostoses  of  foot,  555 
Etxra-articular  disease  of  hip,  301 
of  knee,  318 

FEMUR,  bending  of  neck  of,  see  Coxa 
Vara,  392 
depression  of  neck  of,  see  Coxa  Vara, 

392   ' 
fracture  of  neck  of,  402 
Fingers,  congenital  contraction  of,  437 
treatment  of,  437 
distortions  of,  438 
drop,  see  Mallet  Finger,  438 
jerking,  see  Trigger  Finger,  438 
mallet,  see  ^Slallet  Finger,  438 
snapping,  see  Trigger  Finger,  438 
trigger,  see  Trigger  Finger,  438 
webbed,  437 

etiology  of,  437 
treatment  of,  437 
Flat  foot,  see  Weak  Foot,  507 
Foetal  rhachitis,  367 

cretinism  allied  to,  367 


INDEX. 


635 


Foetal  rhachitis,  etiology,  367 
pathology,  367 
prognosis,  367 
treatment  of,  367 
Poot,  contracted,  534 
deformities  of,  492 
disabilities  of,  492 
flat,  see  the  Weak  Foot,  507 
function  of  the  muscles  of,  502 
general  description  of,  492 
hollow,  534 
exostoses  of,  555 
as  a  mechanism,  506 
movements  of,  496 

plaster  cast  of,  method  of  taking,  524 
relative  strength  of  muscles  of,  tables 

of,  503 
splay,  see  Weak  Foot,  507 
weak,  507 

adjuncts  in  treatment  of,  532 
plaster  strapping,  532 
Thomas  treatment,  532 
anatomy  of,  508 
in  childhood,  519 

out  and  in  toeing  as  symp- 
toms of,  519 
diagnosis  of,  514 
etiology  of,  511 
extreme  types  of,  517 
operative  treatment  for,  532 
pathology  of,  511 
rigid,  527 

other  varieties  of,  531 
treatment  of,  527 

forcible  over-correction 

in,  527 
systematic      manipula- 
tion in,  527 
statistics  of,  512 
symptoms  of,  513 
treatment  of,  521 
attitudes  in,  522 
brace  in,  525 
exercises  in,  523 
the  shoe  in,  521 
support  in,  523 
varieties  of,  516 
Fracture  of  neck  of  femur,  402 
Fragilitas  ossium,  368 
Freidreich'  s  disease,  see  Hereditary  Atax- 
ia, 468 
Functional  affections  of  joints,  471 
causes  of,  472 
diagnosis  of,  472 
treatment  of,  472 
pathogenesis  of  deformity,  190 
Funnel  chest,  187 

GENU  recurvatum,  acquired,  332 
etiology  of,  332 
symptoms  of,  333 
treatment  of,  333 
congenital,  328 

treatment  of,  329 
deformities  accompanied  by,  328 
statistics  of,  328 


Genu  recurvatum,   deformities    accompa- 
nied by,  etiology  of,  329 
Genu  valgum,  405-411 

accommodative  attitude  in,  414 
combined  with  general  rhachitic 
distortions,  415 
with  genu  varum,  415 
etiology  of,  406 
gait  in,  414 
measurements   of   deformity   of, 

417 
outgrowth  of  deformity  of,  409 
pathology,  416 
predisposition   to   deformity  of, 

409 
secondary  deformities  of,  414 
statistics  of,  405 
table  of,  406 
time  of  onset  of,  406 
treatment  of,  417 
by  braces,  419 

duration  of,  420 
exercise  in,  418 
expectant,  417 

manipulation  in,  417 
Lorenz's  operation,  423 
operative,  421 
osteoclasis  in,  422 
osteotomy  in,  421 

cuneiform,  422 
by  plaster  bandage,  421 
posture  in,  418 
Thomas  brace  in,  420 
Wolff'' s,  423 
unilateral,  415 
Genu  varum,  405,  423 
etiology  of,  406 
measurements    of   deformity  in, 

426 
outgrowth  of  deformity  of,  409 
predisposition  to   deformity    in, 

406 
statistics  of,  405 
table  of,  405 
symptoms  of,  425 
time  of  onset  of,  406 
treatment  of,  426 
by  braces,  426 
expectant,  426 
operative,  426 
osteotomy  in,  427 
osteoclasis  in,  427 
Gonorrhceal  arthritis,  208 
statistics  of,  208 
symptoms  of,  208 
treatment  of,  210 
varieties  of,  209 
Gonorrhceal  rheumatism,  see  Gonorrhceal 
Arthritis,  208 
of  spine.  111 

H^MARTHROSIS,  217 
Hsemophilia,  216 
treatment,  217 
Hallux  flexus,  see  Hallux  Rigidus,  548 
rigidus,  548 


636 


INDEX. 


Hallux  rigid  us,  etiology  of,  549 

treatment  of,  549 
Hallux  valgus,  551 

etiology  of,  552 
pathology  of,  552 
symptoms  of,  553 
treatment  of,  553 

cuneiform  osteotomy  in,  554 
operative,  553 
Hallux  varus,  551 

congenital,  see  pigeon  toe,  551 
treatment  of,  551 
Hammer  toe,  554 

symptoms  of,  554 
treatment  of,  554 
Height,  table  of,  190 
Hemiplegia,  treatment  of,  463 
Hereditary  ataxia,  468 

symptoms  of,  469 
' '  High    hip ' '    of    lateral    curvature    of 
spine,  125 
"shoulder"    of  lateral  curvature  of 
spine,  125 
Hip  disease,  see  Tuberculous  Diseases  of 
Hip  Joint,  221 
excision  of,  in  tuberculous  disease  of 
hip  joint,  290 

functional     re- 
sults    after, 
290,  292 
statistics        of, 
289,  291 
Hip,  hysterical,  469 

anterior  dislocation,  380 
bilateral  dislocation  of,  379 

general     symptoms    of, 
380 
congenital  dislocation  of,  373 
diagnosis  of,  380 
etiology,  377 
pathology,  374 
statistics,  373 

table  of,  374 
symptoms,  378 
treatment  of,  382 

intermediate  opera- 
tion, 390 
Lorenz's   operation 

in,  386 
open  operation  in, 

383 
secondary      osteot- 
omy in,  391 
tuberculous  disease  of,  221 
unilateral  dislocation  of,  378 
Hollow  foot,  534 

etiology  of,  534 
symptoms  of,  535 
treatment  of,  537 

operative  of,  537 
Housemaid's  knee,  see  Prepatellar  Bur- 
sitis, 325 
Hutchinson's     index     showing     relative 

depth  of  cliest,  186 
Hysterical  club  foot,  470 

difllerential  diagnosis,  471 


Hj'sterical  equino-varus,  624 
hip,  469 

diagnosis  of,  469 
diflerential,  470 
symptoms  of,  470 
scoliosis,  471 
case  of,  471 
treatment  of,  471 
spine,  115 

symptoms  of,  115 
treatment  of,  116 

IDIOPATHIC  osteopsathyrosis,  see  Frag- 
ilitas  Ossium,  368 
Incidental  lateral  curvature  of  spine,  135 
Infantile  club  foot,  573 

paralysis,  see  Poliomyelitis  Anterior, 

440 
scorbutus,  367 

pathology  of,  368 

symptoms  of,  368 

treatment  of,  368 

In  knee,  see  Genu  Valgum,  405-411 

Injury  of  sacro-iliac  articulation,  119 

of  spine,  55,  108 
Intermediate  operation,  for  congenital  dis- 
location of  hip,  390 

JERKING  finger,   see  Trigger  Finger, 
438 
Joint  disease  in  locomotor  ataxia,  218 

in  affections  of  nervous  system,. 
217,  218 
Joints,  diseases  of,  syphilitic,  206 
acquired,  207 
hereditary,  206 

later  manifestations  in, 
207 
pseudo-paralysis  in,  206 
spina  ventosa  in,  207 
treatment  of,  208 
functional  affections  of,  471 
causes  of,  472 
diagnosis  of,  472 
treatment  of,  472 
neurotic,  see  Joints,  Functional  Affec- 
tions of,  471 
Judson   brace  in  treatment  of   club  foot, 
600 
hip  brace,  255 

KINGSLEY'S  table  for  estimating  flex- 
ion deformity,  244 
Knee,  congenital  contraction  at,  332 

general  contractions  combin- 
ed with,  332 
prognosis  of,  332 
treatment  of,  332 
displacement  of  a  semilunar  cartilage 
in,  327 
cause  of,  327 
treatment  of,  327 
Campbell  brace 
in,  327 
extra -articular  disease  of,  318 
injuries  of,  in  childhood,  324 


INDEX. 


637 


Knee  joint,  internal  derangement  of,  326 
loose  bodies  in.  326 
tuberculous  disease  of,  304 
snapping,  331 

treatment  of,  332 
strains  of,  in  cliildbood,  324 
Knight  brace  in  treatment,  lateral  curva- 
ture of  spine,  177 
Knock  knee,  see  Genu  Valgum,  405-411 
Kyphosis,  182 

of  adolescents,  114 
postural,  183 
of  rhachitis,  109,  183 
treatment  of,  184 

T  AMINECTOMY,  98 
Li    Latent  tuberculosis,  194 
Lateral  curvature  of  spine,  120 
congenital,  135 
diagnosis  of,  141 

mobility  tests  of,  in,  142 
posture  in,  141 
due  to  occupation,  135 
effiects  of  deformity  of,  124 
fixed  deformity  in,  121 
forcible  correction  of  defor- 
mity of,  177 
combined  with 
fixation,  178 
habitual  deformity  in,  121 
hereditary  influence  in,  137 
the  "high  hip"  of,  125 
_  "shoulder"  of,  125 
incidental,  135 
lateral  deviation  in,  124 
occupation  as  a  factor  in,  137 
pathology  of,  126 
prevention  of  deformity  of, 

146 
prognosis  of,  143 
record  of  case,  142 
rhachitic,  135 
rotation  in,  123 
secondary  to  deformity  else- 
where, 133 
to   disease   within    tho- 
racic walls,  134 
to  paralysis,  133 
statistics  of,  130 
age,  131 
frequency,  130 
sex,  130 
symptoms  of,  141 
treatment  of,  147 

by  braces,  148,  176 
corsets  in,  177 
duration  of,  180 
exercises  in,  151,  164 
general,  180 
high  shoe  in,  180 
Knight  brace  in,  177 
self-suspension  in,  175 
Teschner's  exercises  in, 

151 
Volkmann  seat  in,  180 
varieties  of  deformity  in,  139 


' '  Late  rickets, ' '  366 

Ligamentum  patellie,  elongation  of,  331 
etiology,  331 
symptoms,  331 
treatment,  331 
Linear   osteotomy  in   treatment   of   coxa 

vara,  400 
Lipoma,  arborescens  tuberculosum,  201 
Locomotor  ataxia,  joint  disease  in,  218 
Lordosis,  184 

treatment  of,  185 
Lorenz  operation,  for  congenital  disloca- 
tion of  hip,  386 
for  genu  valgum,  423 
reclination  gypsbettes    in  treatment. 
Pott's  disease,  60 
Lovett's  table  for  estimating  lateral  dis- 
tortion in  tuberculous  disease,  hip  joint, 
242 
Lumbar  Pott' s  disease  in  infancy,  peculi- 
arities of,  44 

MALIGNANT  disease  of  spine,  107 
diagnosis  of,  107 
Malleotomy  in  treatment  of  club  foot,  591 
Mallet  finger,  438 
Metatarsalgia,  anterioi',  538 
etiology  of,  538 

influence  of  shoe  in  causing  dis- 
ability and  pain  in,  541 
pathology  of,  538 
treatment  of,  542 
brace  for,  543 
support  in,  543 
Metzger-Goldthwait  apparatus,  105 
Mollitis  ossium,  see  Osteomalacia,  369 
Morbus  coxae,  see  Tuberculous  Disease  of 

Hip  Joint,  221 
Morton' s  neuralgia,  see  Metatarsalgia  An- 
terior, 538 
Muscles  of  leg,  relative  strength  of,  628 

pectoral,  defective  formation  of,    188 
Muscular  atrophy,  progressive,  466 

dystrophy,  467 
Myelopathic  paralysis,  466 

NECK,  deformities  of,  in  anterior  polio- 
myelitis, 447,  see  torticollis,  474 
Nervous  system  affections  of,  joint  disease 
in,  217,  218 
diseases  of,  440 
Neuritis,  469 

treatment  of,  469 
Neurotic  joints,  see  Joints,  Functional  Af- 
fections of,  471 
spine,  114 

symptoms  of,  115 
treatment  of,  115 
Non-deforming    club    foot,    see    Hollow 

Foot,  534 
Non-tuberculous   affections   of  the  ankle 
joint,  342 
of  the  hip  joint,  300 
of  the  knee  joint,  324 
of  the  spine,  107 
disease  of  joints,  206 


638 


INDEX. 


OBSTETRICAL  paralysis,  431 
treatment  of,  431 
Ocular  torticollis,  491 
(Edema  of  foot,  congenital,  608 
Open  operation,  for  congenital  dislocation 

of  hip,  383 
Osteitis  deformans,  370 

deformities  of,  370 
of  spine,  114 
Osteo-arthritis,  212 

atrophic  form,  214 
etiology  of,  213  ^ 
of  knee  joint,  325 

symptoms  of,  325 
treatment  of,  325 
localized  form,  214 
multiple  form,  213 

statistics  of,  214 
pathology,  212 

of   spine,   see  spondylitis  defor- 
mans, 111 
case  of,  113 
symptoms  of,  215 
treatment  of,  215 

by  apparatus,  216 
by    forcible     manipulation, 
216 
varieties  of,  213 
Osteo-arthropathy,  370 

treatment  of,  371 
Osteoclasis  in  treatment  of  genu  valgum, 
422 
in  treatment  of  genu  varum,  427 
in  treatment  of  talipes,  596 
Osteomalacia,  369 
in  childhood,  369 
cases  of,  369 
treatment  of,  370 
deformities  of,  369 
symptoms  of,  369 
Osteomyelitis,  infectious  localized,  212 
of  spine,  108 

symptoms  of,  108 
treatment  of,  108 
Osteotomy   for     correction   deformity   of 
tuberculous  disease  hip  joint,  293 
cuneiform  in  treatment  of  club  foot, 
599 
in  treatment  of  coxa  vara,  401 
in   treatment  of    hallux  valgus, 
554 
linear  in    treatment  of    coxa  vara, 

400 
secondary  in  treatment, anterior  polio- 
myelitis, of  club  foot,  600 
in  treatment  of,  457 
of  club  foot,  598 
of  genu  valgum,  421 
varum,  427 
Over-lapping  toes,  555 

PAGET' S  disease,  370 
see  osteitis  deformans  of  spine,  114 
Painful  great  toe,  see  Hallux  Rigidus,  548 
joint  in  older  subjects,  550 
heel,  547 


Pain  in  lower  part  of  back,  116 

treatment  of,  116 
Paralysis,  acquired,  459,  462 
deformities  in,  462 
disability  of,  463 
loss  of  growth  in,  463 
Sach'  s  classification  of  causes  and 
effects  of,   459 
of  anterior  muscles  of  leg  in  anterior 
poliomyelitis,    450,    see    Talipes 
Poliomyelitis,  444 
of  arm  in  anterior  poliomyelitis,  465 
cerebral,  in  childhood,  459 
congenita],  459,  461 

deformities  in,  462 
electrical  test  for,  in  anterior  polio- 
myelitis, 445 
infantile,  see  Poliomyelitis,  Anterior, 

440 
muscles  of  hip  in  anterior  poliomye- 
litis, 454 
myelopathic,  466 

Aran-Duchenne  type  of,  466 
Charcot-Marie-Tooth  type  of,  466 
myopathic,  467 
obstetrical,  431 

treatment  of,  431 
of  posterior  muscles  of  leg  in  anterior 

poliomyelitis,  451 
in  Pott' s  disease,  93 
pseudo-hypertrophic  muscular,  468 
diagnosis  of,  468 
treatment  of,  468 
spastic,  459 

etiology  of,  459 
pathology  of,  459 
prognosis  of,  466 
statistics  of  distribution  of,   459 
statistics  of  mental  impairment  in,  461 
symptoms  of,  460 
mental,  460 
motor,  460 
of  thigh  muscles,  anterior  poliomye- 
litis, 451 
Paralytic  scoliosis  in  anterior  poliomye- 
litis, 454 
torticollis,  491 
Paraplegia,  treatment  of,  93,  464 
Patella,   congenital  displacement  of,   329 
rudimentary  or  absent,  329 

treatment  of,  329 
slipping,  330 
etiology,  330 
symptoms,  330 
treatment,  330 
operative,  330 
Pathogenesis  of  deformity,  functional,  190 
Pectoral  muscles,  defective  formation  of, 

188 
Pectus  carinatum,  see  Pigeon  Chest,  186 

excavatum,  see  Funnel  Chest,  187 
Pelvic  abscess  in  lumbar  Pott's  disease,  40 
Periarthritis  of  the  shoulder,  358 
symptoms  of,  358 
treatment  of,  358 
Peronei  tendons,  displacement  of,  555 


INDEX. 


639 


Pes  planus,  518 

Phalanges,    congenital    displacement   of, 

438       • 
Phelps'  bed  in  treatment  Pott's  disease, 
60 
hip  splint,  278 

operation  for  immediate  correction  of 
deformity  of  club  foot,  596 
Pigeon  breast,  364 
chest,  186 

treatment  of,  187 
toe,  551 
Plantalgia,  see  Plantar  Neuralgia,  548 
Plantar  fascia,  division  of,  in  treatment 
of  club  foot,  593 
of  hollow  foot,  537 
Plantar  neuralgia,  548 

treatment  of,  548 
Plaster  bandage  in  treatment  tuberculous 
disease  hip  joint,  265,  266 
cast  of  foot,  method  of  taking,  524 
corset,  76 
jacket,  application  of,  70 

in  recumbency,  74 
Poliomyelitis,  anterior,  acute,  440 

causes  of  deformity  of,  445 
deformities  of  lower  extrem- 
ity in,  450 
of  neck  in,  447 
secondary  in,  449 
of  trunk  in,  448 
of  upper   extremity  in, 
447 
diagnosis  of,  443 

differential,  443,  444 
etiology  of,  441 
pathology  of,  440 
prognosis  of,  444 
retardation    of    growth    in, 

449_ 
statistics  of,  441 

tables  of,  441,  442 
symptoms  of,  442 
treatment  of,  450 

mechanical,    principles 

of,  450 

prevention  of  deformitv 

_  in,  450 

arthrodesis  in,  456 

osteotomy  in,  457 

paralysis  in,  444 

of  anterior  muscles  of  leg  in, 

450 
of  arm  in,  455 
electrical  test  for,  445 
of  posterior  muscles  of  leg, 

451 
of  thigh  muscles,  451,  454 
paralytic  scoliosis  in,  454 

torticollis  in,  490 
reduction  of  deformity  of,  455 

by  braces,  456 
tendon  transplantation  in,  456 
treatment  of,  operative,  455,  457 
Popliteal  region,  burste  and  cysts  in,  326 
Posterior  torticollis,  491 


Pott's  disease,  see  Tuberculous  Disease  of 
Spine,  17 
complications  of,  87 
abscess,  87 

in  different  regions,  88 
treatment  of,  89 
paralysis  in,  93 

duration  of,  95 

prognosis,  95 
statistics    of    frequency 

liability  to,  in  dif- 
ferent regions,  94 
time  of  onset,  95 
symptoms  of,  95 
treatment  of,  97 
duration  of,  99 
operative,  98 
forcible  correction  deformity  of, 
101  _ 
statistics  of  results 

of,  102 
selection    of     cases 
for,  102 
gradual  correction  of   deformity 
of,  104 
Metzger-G  oldthwait 
apparatus  for,  105 
local  paralysis  in,  98 
recurrence  of,  100 
secondary  deformities,  100 
statistics  of,  21 
age,  22 
frequency,  21 
sex,  22 
situation,  22 
Pott's  fracture,  624 
Pott's  paraplegia,  95 

symptoms  of,  95 
Pretibial  bursa,  enlargement  of  superficial, 

326 
Prepatellar  bursitis,  325 

treatment  of,  325 
Pretibial  bursitis,  326 

symptoms  of,  326 
treatment  of,  326 
Progressive  muscular  atrophy,  466 
Pseudo-hypertrophic  muscular  paralysis, 
468 
diagnosis  of,  468 
treatment  of,  468 
Pseudo-paralysis  in  rhachitis,  34 
in  syphilitic  disease,  206 
Psychical  torticollis,  491 
Puerperal  arthritis,  210 

RETENTION  brace  in  treatment  of  club 
foot,  581 
Ketro-calcaneo   bursitis,  see    achillo-bur- 

sitis,  544 
Rhachitic  distortions,  general,  429 
kyphosis,  109 

lateral  cdrvature  of  spine,  135 
rosary,  363 

spine,  45,  109,  110,  183,  364 
treatment  of,  110 


640 


INDEX. 


Khachitic  torticollis,  491 
Rhachitis,  361 

deformities  of,  362 

caput  quadratum,  363 
' '  craniotabes, ' '  363 
"  double  joints,"  363 
pigeon  breast,  364 
"  rhachitic  rosarv,"  363 
attitude,  364 
pseudo-paral  vsis,  364 
spine,  45,  109,  110,  183,  364 
etiology  of,  361 
foetal,  367 

cretinism  allied  to,  367 
etiology,  367 
pathology,  367 
prognosis,  367 
treatment  of,  367 
kyphosis  of,  109,  183 
pathology  of,  361 
prognosis  of,  365 
symptoms  of,  362 
treatment  of,  365 

Bradford  frame  in,  366 
prevention  of  deformity  in,   366 
Kheumatism  of  spine,  56,  see  also  Spondy- 
litis Deformans,  111 
Rheumatoid  arthritis,  see  Osteo-arthritis, 
212 
of  knee  joint,  325 
of  spine,  chronic,  113 
Ribs,  absence  of,  188 
Rice  bodies  in  tuberculous  joint  disease, 

201 
Rickets,  see  Rhachitis,  361 
Rigid  Hat  foot,  see  Rigid  Weak  Foot,  527 
weak  foot,  527 

treatment  of,  527 

forcible  over-correction 

in,  527 
plaster  strapping  in,  532 
systematic  manipulation 

in,  527 
Thomas,  532 
Rotary  lateral  curvature,  see  lateral  curva- 
ture of  the  spine,  120 
Rudimentary  patella,  329 

SACRO-ILIAC  articulation,   injury   of, 
119 
disease  of,  117 

abscess  in,  119 
diagnosis  of,  118 
prognosis  of,  118 
symptoms  of,  117 
treatment  of,  118 

Thomas   hip    brace   in, 
119 
Scapula,  congenital  elevation  of,  185 
etiology  of,  185 
treatment  of,  186 
Sciatica,  deformity  secondary  to,  117,  119 
Sciatic   scoliosis,  see   Sciatica,   Deformity 

Secondary  to,  117 
Scoliosis,  see  Lateral  Curvature  of  Spine, 
120 


Scoliosis,  hysterical,  471 
case  of,  471 
treatment  of,  471 
paralytic  in  anterior  poliomyelitis,  454 
total,"  122 
Scorbutus,  hemorrhage  in,  217 
infantile,  367 

symptoms  of,  368 
treatment  of,  368 
Scurvy,  see  Scorbutus,  Infantile,  367 

rickets,  see  Scorbutus,  Infantile,  367 
Secondary,    hypertrophic    osteo-arthrop- 

athy,  370 
Shoes,  556 

Shoulder,  chronic  bursitis  at,  359 
congenital  dislocation  of,  430 

treatment  of,  430 
joint,  tuberculous  disease  of,  348 
periarthritis  of,  358 
symptoms  of,  358 
treatment  of,  358 
recurrent  dislocation  of,  432 
treatment  of,  432 
operative,  433 
Sinuses  in  tuberculous  disease  hip  joint, 

treatment  of,  289 
Slipping  patella,  330 
Snapping  finger,  see  Trigger  Finger,  438 

knee,  331 
Spasmodic  torticollis,  486 
Spastic  paralysis,  459 

torticollis,  480 
Spina  bifida  and  talipes,  608 
ventosa,  356 

statistics  of,  356 

in  syphilitic  disease,  207 

treatment,  357 

operative,  357 
Spine,  actinomycosis  of,  108 

antero-posterior  deformities  of,  182 
kyphosis,  183 
postural,  183 
of    rhachitis,    109, 
183,  364 
lordosis,  184 

treatment  of,  185 
treatment  of,  184 
arthritis  of.  111 

treatment  of,  111 
changes  in   antero-posterior  contour 

of,  125 
contour  and  flexibility  of  normal,  29 

variations  in,  181 
divisions  of,  30 
injury  of,  55,  108 
gonorrlia?al  rheumatism  of,  111 
hysterical,  115 

symptoms  of,  115 
treatment  of,  1 16 
landmarks  of,  32 
lateral  curvature  of,  120 
congenital,  135 
diagnosis,  141 

mobility    tests    of,    in, 

142 
posture  in,  141 


INDEX. 


641 


Spine,  lateral  posture  in,  due  to  occupa- 
tion, 135,  137 
effects  of  deformity  of,  124 
fixed  deformity  in,  121 
forcible  correction  of  defor- 
mity in,  177 
combined  with 
fixation,  178 
habitual  deformity  in,  121 
hereditary  influence  in,  137 
the  "high  hip"  of,  125 
"shoulder"  of,  125 
incidental,  135 
lateral  deviation  in,  124 
pathology  of,  126 
prevention  of  deformity  in, 

146 
prognosis  of,  143 
record  of  case,  142 
rhachitic,  135 
rotation  in^  123 
secondary  to  deformity  else- 
where, 133 
to  disease  within  thor- 
acic walls,  134 
to  paralysis,  133 
statistics,  130 
age,  131 
frequency,  130 
sex,  130 
symptoms  of,  141 
treatment  of,  147 

by  braces,  148,  176 
corsets  in,  177 
duration  of,  180 
exercise  in,  151,  164 
Teschner's,  151 
general,  180 
Knight  brace  in,  177 
high  shoe  in,  180 
self-suspension  in,  175 
Volkmann  seat  in,  180 
varieties  of  deformity  in,  139 
malignant  disease  of,  107 
diagnosis  of,  107 
neurotic,  ll4 

symptoms  of,  115 
treatment  of,  115 
osteitis  deformans  of,  114 
osteo-arthritis  of,  see  Spondylitis  De- 
formans, 111 
case  of,  113 
osteomyelitis  of,  108 
symptoms  of,  108 
treatment  of,  108 
physiological  movements  of,  120 
rhachitic,  45,  109,  110,  183,  364 

treatment  of,  110 
rheumatism  of,    see  Spondylitis  De- 
formans, 111 
rheumatoid  arthritis  of,  case  of,  113 
syphilis  of,  107 

diagnosis  of,  107 
traumatic  spondylitis,  1 09 
tuberculous  disease  of,  17 
typhoid,  the,  110 
41 


Spine,  typhoid,  the,  treatment  of,  110 

variations  in  contour  of,  181 
Splay  foot,  see  Weak  Foot,  507 
Spondylolisthesis,  116 
Spondyloze  Ehizomelique,    see    Spondy- 
litis Deformans,  111 
Spondylitis  deformans,  111 
case  of,  113 
pathology  of.  111 
symptoms  of,  112 
treatment  of,  114 
traumatic,  109 
Spontaneous      amputations,      congenital, 

608 
Sprain  of  the  ankle,  342 
chronic,  344 
of  wrist,  359 

chronic,  359 
Sprengel's  deformity,  see  congenital  ele- 
vation of  scapula,  185 
Statistics  of  anterior  poliomyelitis,  441 
of  club  hand,  435 

of  congenital  dislocation  at  hip  joint, 
373 
talipes  calcaneus,  604 
equinus,  604 
valgus,  605 
calcaneo-valgus,  605 
equino-valgus,  605 

associated    with    congenital 

absence  fibula,  606 
varus  associated   with    con- 
genital     absence      tibia, 
607 
of  coxa  vara,  394 
genu  valgum,  405 

varum,  405 
lateral  curvature  of  spine,  130 
age,  131 
frequency,  130 
sex,  130 
varieties,  140 
of  osteo-arthritis,  214 
of  Pott' s  disease,  21 
age,  22 
frequency,  21 
sex,  22 

situation  of,  22 
of  results  of    tuberculous  joint   dis- 
ease, 203,  295,  298,  322,  323,  341, 
349,  354 
of  spina  ventosa,  356 
of  synovial  disease  of  joints,  201 
of  talipes,  566 

foot  affected,  567 
relative    frequency   of    different 
forms,  acquired,  568 

congenital,  567 
comparative  frequency  of  differ- 
ent forms,  congenital  and  ac- 
quired, 568 
sex,  567 
of  torticollis,  474 
acquired,  481 

table  of,  481 
spasmodic,  487 


642 


INDEX, 


vStatistics  of  tuberculous  disease  of  elbow 
joint,  351,  354 
hip  joint,  224 

age,    197,   198,   225 
at     incipiency 
table  of,  22 
deformity  in,  248 
excision,    289,    291 
functional    results, 

259,  297,  298 
mortality,  295 
retardation    of 
growth,  tables  of, 
238,  239 
sex,  197,  225 
side   affected,    197, 
225 
of  shoulder  joint,  348,  349 
of  wrist  joint,  354 
of  weak  foot,  512 
Stemo-mastoid  muscle,  hsematoma  of,  477 
Stiffness  of  vertebral  column,  see  Spondy- 
litis Deformans,  111 
Strain  of  the  tendo  Achillis,  547 
Symptoms  of  abscess  in  Pott's  disease,  87 
of  achillo-bursitis,  545 
posterior,  547 
of  actinomycosis  of  spine,  108 
of  acquired  genu  recurvatum,  333 
talipes  calcaneus,  618 
equinus,  612 
of  acromegalia,  372 
of  acute  anterior  poliomyelitis,  442 

torticollis,  481 
of  anchylosis,  218 
of  anterior  bow  leg,  429 

metatarsalgia,  538 
of  arthritis  deformans  at  hip,  302 
of  bilateral  dislocation  at  hip  joint, 

380 
of  bow  leg,  423 
of  bursEe  at  hip,  302 
at  knee,  326 
at  shoulder,  359 
of  calcaneo-bursitis,  547 
of  Charcot' s  disease,  217 
of  club  hand,  434 
of  congenital  club  foot,  572 

dislocation  of  hip  joint,  378 
of  shoulder  joint,  430 
of  coxa  vara,  394 
of  cubitus  valgus,  433 

varus,  433 
of  displacement  of  peronei  tendons, 

555 
of  Dupuytren's  contraction,  439 
of  elevation  of   scapula,  185 
of  elongation  of  iigamentum  patellae, 

831 
of  epiphysitis,  212 

at  hip  joint,  301 
of  erythromelalgia,  548 
of  extra-articular  disease  at  hip  joint, 

301 
of  flat  chest,  186 
of  fcetal  rhachitis,  367 


Symptoms  of  funnel  chest,  187 

of  genu  recurvatum,  acquired, [332 
congenital,  328 

varum,  425 
of  gonorrhceal  arthritis,  208 

of-  spine,  110 
of  hsemarthrosis,  217 
of  haemophilia,  210 
of  hallux  rigidus,  548 

valgus,  553 
of  hammer  toe,  554 
of  hereditary  ataxia,  469 
of  hollow  foot,  535 
of  hysterical  club  foot,  470 

hip,  470 

scoliosis,  471 

spine,  115 
of  infantile  scorbutus,  368 
of  infectious  arthritis,  210 
of  injurv  of  hip,  300 

of  knee,  324 

of  spine,  108 
of  internal  derangement  of  knee,  327 
of  knock  knee,  412 
of  kyphosis,  182 
of  late  rickets,  366 
of  lateral  curvature  of  spine,  141 
of  lordosis,  184 

of  malignant  disease  of  spine, '107 
of  mallet  finger,  438 
of  neuritis,  469 
of  neurotic  joints,  471 

spine,  115 
of  obstetrical  paralysis,  431 
of  osteo-arthritis,  215 

of  knee  joint,  325 
of  osteomalacia,  369 
of  osteomyelitis  of  spine,  108 
of  osteitis  deformans,  114,  370 
of  paralysis,  442,  460 

in  Pott's  disease,  95 
of  periarthritis  of  shoulder,  358 
of  pigeon  chest,  186 
of  plantar  neuralgia,  548 
of  Pott's  paraplegia,  95 
of  prepatellar  bursitis,  325 
oi  pretibial  bursitis,  326 
of  recurrent  dislocation  of  shoulder, 

432 
of  rhacliitis,  362 
of  sacro-iliac  disease,  117 
of  sciatic  scoliosis,  117 
of  scorbutus,  217,  367 
of  slipping  patella,  330 
of  snapping  knee,  331 
of  spastic  paralysis,  459 
of  spina  ventosa,  356 
of  spondylitis  deformans,  112 
of  spondylolisthesis,  116 
of  sprain  of  ankle,  342 
of  syphilitic  disease  of  joints,  206 
of  syphilis  of  spine,  107 
of  talipes  acquired,  609 

congenital,  560 
of  teno-synovitis,  346 
of  torticollis,  acquired,  479 


INDEX. 


643 


Symptoms  of  torticolRs,  congenital,  475 
.  spasmodic,  486 
spastic,  480 
of  trigger  finger,  438 
of  tuberculous  disease  of  ankle  joint, 
336 
of  elbow  joint,  351 
of  hip  joint,  225 
of  knee  joint,  306 
of  shoulder  joint,  349 
■  of  spine,  24 
of  tarsus,  341 
of  wrist  joint,  355 
of  unilateral  coxa  va-ra,  396 
of  weak  foot,  513 
of  webbed  fingers,  437 
Synovial  disease  of  joints,  statistics  of,  201 
in  tuberculous   disease   of   knee 
joint,  318 
treatment     of, 
318 
c  a  r  b  o  lie 
acid  in, 
318 
c  h 1 o  r  ide 
o  f    zinc 
in,  318 
i  o  d  of  orm 
injection 
in,  319 
venous 
stasis  in, 
319 
Synovitis,  324 
chronic,  324 

treatment  of,  324 

aspiration  in,  325 
braces  in,  325 
treatment  of,  324 

plaster  strapping  in,  324 
Syphilitic  disease  of  joints,  206 
acquired,  207 
hereditary,  206 

later  manifestations  in, 
207 
pseudo-paralysis  in,  206 
spina  ventosa  in,  207 
treatment  of,  208 
of  spine,  107 

diagnosis  of,  107 

TABLE  of  age  at  incipiency  tuberculous 
disease  ankle  joint, 335 
elbow  joint,  351 
hip  joint,  225 
knee  joint,  306 
of    shoulder  joint, 

349 
of  spine,  22 
of  wrist  joint,   355 
of  patients  treated  at  Tubingen  for 
tuberculous    disease    ankle    joint, 
336 
Kingsley's,  244 
Lovett's,  242 
of  statistics  acquired  torticollis,  481 


Table  of  anterior  poliomyelitis,  441,  442 
of  congenital  dislocation  of  hip 

joint,  374 
of  coxa  vara,  395 
of  genu  valgum,  406 

varum,  405 
of  lateral  curvature  of  spine,  130 
of  normal  development,  190 
of  talipes,  567,  568 
Talipes,  560 

acquired,  609 

etiology  of,  609 

development  of  deformity  in,  609 
differential  diagnosis  in,  610 
statistics  of,  566 

foot  affected,  567 

relative  frequency,  different 

forms,  568 
sex,  567 
arcuatus,  see  Hollow  Foot,  534 
calcaneo-valgus,  622 

statistics  of,  605 
treatment  of,  622 
-varus,  622 

statistics  of,  605 
treatment  of,  622 
calcaneus,  acquired,  616 

astragalectomy  for,  620 
development  of  deformity  of, 

617 
symptoms  of,  618 
treatment  of,  618 

operative,  619 
Willett's  operation  for,  619 
congenital,  604 

statistics  of,  604 
treatment  of,  604 
cavus,  see  Hollow  Foot,  534 

statistics  of,  605 
congenital,  562 

etiology  of,  563 
statistics  of,  566 

foot  affected,  567 

relative  frequency  different 

forms,  567 
sex,  567 
equino-cavus,  statistics  of,  605 
valgus,  acquired,  623 

associated    with    congenital 
absence      of 
fibula,  606 
etiology  of,  607 
statistics  of,  606 
treatment     of, 
607 
statistics  of,  605 
treatment  of,  623 
varus,  569 

acquired,  623 
treatment  of,  623 

cuneiform  osteotomy  in, 
623 
equinus,  acquired,  611 
etiology  of,  612 
immediate  correction  of  de- 
formity of,  614 


644 


INDEX. 


Talipes,  equinus,  Thomas  wrench  for,  614 
effect  of,  615 
prognosis  of,  613 
symptoms  of,  612 
treatment  of,  613 

Shaffer  extension  brace 
in,  614 
congenital,  604 

statistics  of,  604 
etiology  of,  562 

paralytic,  tendon  transplantation  for 
the  relief  of,  624 
other  methods,  625 
Parish's  operation, 
625 
plantaris,  see  Hollow  Foot,  534 
Talipes  and  spina  bifida,  608 

valgo-cavus,  statistics  of,  605 
valgus,  congenital,  605 

statistics  of,  605 
varieties  of,  560 

varus   associated   congenital   absence 
tibia,  607 

prognosis      of, 

607  _ 
statistics  of,  607 
treatment      of, 
607 
congenital,  603 
Tarsus,  tuberculous  disease  of,  341 
Taylor  back  brace,  63 

foot  brace,  581,  582 
Taylor  hip  braces,  256,  279,  281 
Tendo  Achillis,  division  of,  in  treatment 
of  clubfoot,  592 
strain  of,  547 
Tendon  splicing,  629 

transplantation  for  relief  of  paralytic 
talipes,  624 
Kicoladoni's  opera- 
tion, 624 
Parish's  operation, 

625 
other    methods  of, 
625  _ 
in  treatment  of  anterior  poliomy- 
elitis, 456,  see  Talipes 
Teno-synovitis,  345 

at  ankle,  346 
symptoms  of,  346 
treatment  of,  347 
tuberculous,  347 
at  wrist,  360 
Tenotomy,  subcutaneous,  in  treatment  of 

talipes,  591 
Teschner*  s  exercises  in  treatment  of  lateral 

curvature  of  spine,  151 
Thomas  brace,  in  treatment  of  genu  val- 
gum, 420 
tuberculous     disease    ankle 
joint,  340 
collar,  79 
hip     brace   in   treatment    sacro-iliac 

disease,  119 
knee    brace   in   treatment   of   tuber- 
culous disease  of  knee  joint,  314 


Thomas  knee  brace,  description  of,  315 
method  forcible  correction  of  deform- 
ity of  club  foot,  595 
treatment    tuberculous    disease,    hip 

joint,  260 
hip  splint,  261 

wrench  in  treatment  of  talipes,  595, 
614 
Tibialis  anticus,  division  of,  in  treatment 
of  club  foot,  593 
posticus,  division  of,  in  treatment  of 
club  foot,  593 
Toes,  over-lapping,  555 
Torticollis,  474 
acquired,  479 

statistics  of,  481 
table  of,  481 
varieties  of,  479 
acute,  diagnosis  of,  482 
differential,  483 
etiology  of,  479 
spastic,  480 

causes  of,  480 
symptoms  of,  481 
congenital,  475 

deformity  of,  475 
etiology  of,  477 

hsematoma  of  sterno-mastoid  mus- 
cle in,  477 
pathology  of,  478 
secondary  distortions  of,  476 
following  diphtheritic  paralysis,  491 
ocular,  491 
paralytic,  490 
posterior,  491 
psychical,  491 
rhachitic,  491 
spasmodic,  486 

etiology  of,  487 
pathology  of,  487 
prognosis  of,  487 
statistics  of,  487 
treatment  of,  487 

operation  in,  488 
statistics  of,  474 
treatment  of,  483 

correction  of  deformity  in,  484 

by  subcutaneous   tenot- 
omy, 484 
open  operation,  484 
Traction  hip  brace,  251 

application  of,  254 
Traumatic  coxa  vara,  402 

diagnosis  of,  402 
treatment  of,  402 
separation   of   epiphysis   of   head   of 

femur,  404 
spondylitis,  109 
valgus,  624 
Treatment  of  abscess  in  Pott's  disease,f89 
in    tuberculous    disease    of    hip 
joint,  287 
of  knee  joint,  318 
of  achillo-bnrsitis,  546 
posterior,  547 
of  actinomycosis  of  spine,  108 


INDEX. 


645 


Treatment  of  acquired  genu  recurvatum, 
333 
of  luxation  of  clavicle,  188 
of  talipes  calcaneus,  618 
of  equino-valgus,  623 

-varus,  623 
of  equinus,  613 
of  valgus,  624 
of  varus,  624 
of  acute  anterior  poliomyelitis,  450 

of  torticollis,  483 
of  anchylosis,  219 
of  anterior  bow  leg,  429 

of  metatarsalgia,  542 
of  arthritis  following  infectious  dis- 
ease, 211 
of  spine,   111 
deformans  at  hip,  303 
of  bilateral  dislocation  of  hip  joint, 

382 
of  bow  leg,  426 
of  bursse  at  hip,  302 
of  knee,  326 
of  shoulder,  359 
of  calcaneo-bursitis,  547 
of  Charcot's  disease,  218 
of  club  hand,  436 

of  congenital  absence  of  fibula,  607 
of  radius,  436 
of  ribs,  188 
of  tibia,  607 
calcaneus,  604 
club  foot,  572  _ 
contraction  of  fingers,  437 

at  knee,  332 
defect  of  pectoral  muscles,  188 
deficiencies  of  the  foot,  608 
dislocation  of  hip  joint,  382 

of  shoulder,  430 
elevation  of  scapula,  186 
torticollis,  483 
of  coxa  vara,  399 

unilateral,  400 
bilateral,  401 
of  displacement  of  peronei   tendons, 

556 
of  double  tuberculous  disease  of  hip 

joints,  284 
of  Dupuytren's  contraction,  439 
of  elongation  of  ligamentum  patellse, 

331 
of  epiphysitis,  212,  300 

at  hip,  301 
of  extra-articular  disease  at  hip  joint, 

301 
of  flat  chest,  186 
of  foetal  rhachitis,  367 
of  funnel  chest,  188 
of  functional  affections  of  joints,  472 
of  genu  recurvatum,  acquired,  333 
congenital,  329 
valgum,  417 
varum,  426 
of  gonorrhceal  arthritis,  210 

of  spine,  110 
of  hsemarthrosis,  217 


Treatment  of  haemophilia,  217 
of  hallux  rigidus,  549 

valgus,  553 

varus,  551 
of  hammer  toe,  554 
of  hemiplegia,  463 
of  hereditary  ataxia,  469 
of  hollow  foot,  535 
of  hysterical  club  foot,  471 

hip,  471 

scoliosis,  471 

spine,  116 
of  infantile  scorbutus,  368 
of  infectious  arthritis,  210 
of  knee  joint,  325 
of  injury  of  hip,  300 

knee,  324 

spine,  109 
of  internal  derangement  of  knee,  327 
of  knock  knee,  412 
of  kyphosis,  184 

of  lateral  curvature  of  the  spine,  147 
of  lordosis,  185 

of  malignant  disease  of  spine,  108 
of  mallet  finger,  438 
of  neuritis,  469 
of  neurotic  joints,  471 
of  neurotic  spine,  115 
of  obstetrical  paralysis,  431 
of  osteo-arthritis,  215 

at  hip  joint,  302 
at  knee  joint,  325 

-arthropathy,  371 
of  osteomalacia,  369 

in  childhood,  370 
of  osteomyelitis  of  spine,  108 
of  osteitis  deformans,  370 
of  pain  in  lower  part  of  back,  116 
of  paralysis,  450,  464,  468 

in  tuberculous  disease  of  spine,  97 
of  paraplegia,  97,  464 
of  periarthritis  of  shoulder,  358 
of  pigeon  chest,  187 
of  plantar  neuralgia,  548 
of  prepatellar  bursitis,  325 
of  pretibial  bursitis,  326 
of  pseudo-hypertrophic  muscular  pa- 
ralysis, 468 
of  recurrent  dislocation  of  shoulder, 

432 
of  rhachitis,  365 

foetal,  367 
of  rhachitic  distortions,  365 
of  rudimentary  or  absent  patella,  329 
of  sacro-iliac  disease,  118 
of  sciatic  scoliosis,  117 
of  scorbutus,  217,  368 
of  sinuses  in  tuberculous  disease   of 

hip  joint,  289 
of  slipping  patella,  330 
of  snapping  knee,  332 
of  spasmodic  torticollis,  487 
of  spastic  paralysis,  463 

torticollis,  486 
of  spina  ventosa,  357 
of  spondylitis  deformans,  114 


646 


INDEX. 


Treatment  of  spondylolisthesis,  117 
of  sprain  of  ankle,  343 
chronic,  345 
of  wrist,  359 

chronic,  359 
of  subluxation  of  wrist,  434 
of    synovial    tuberculous    disease   of 

knee  joint,  318 
of  synovitis,  324 
chronic,  324 
of  syphilitic  disease  of  joints,  acquir- 
ed, 208 
hereditary,  208 
of  syphilis  of  spine,  107 
of  talipes  acquired,  613 
calcaneus,  618 
calcaneo-valgus,  622 

-varus,  622 
cavus,  see  Hollow  Foot,  535 
equinus,  613 
equino-valgus,  624 

-varus,  624 
planus,  see  Weak  Foot,  521 
valgus,  624 
varus,  624 
congenital,  573 
calcaneus,  604 
calcaneo-valgus,  605 

-varus,  605 
cavus,  605 
equinus,  604 
equino-valgus,  605 

-varus,  605 
valgus,  605 
varus,  604 
of  teno-synovitis,  347 
of  ankle,  347 
of  wrist,  360  _ 
of  torticollis  acquired,  483 
congenital,  483 
chronic,  483 
spasmodic,  487 
spastic,  486 
of  traumatic  coxa  vara,  402 

separation   of    the   epiphysis   of 
head  of  femur,  403 
of  trigger  finger,  438 
of  tuberculous  disease  of  ankle  joint, 
339 
of  elbow  joint,  352 
of  hip  joint,  249 
of  knee  joint,  311 
of  shoulder  joint,  350 
of  spine,  58 
of  tarsus,  342 
of  wrist  joint,  355 
joint  disease,  204 
of  typhoid  spine,  110 
of  weak  foot,  521 

rigid,  527 
of  webbed  fingers,  437 
Trigger  finger,  438 

etiology  of,  438 
treatment  of,  438 
Trunk,   deformities  of,  in  anterior  polio- 
myelitis, 448 


Tuberculosis,  arborescent  synovial,  201 

latent,  194 
Tuberculous  arthritis,  acute,  212 
disease  of  ankle  joint,  334 

abscess  in,  334 

situation  of  disease, 
335 
deformity  of,  336 
etiology  of,  335 

statistics  of,  335 
age   at   incipi- 
ency, table  of, 
335 
age  of  patients 
treated        at 
T  ii  b  i  n  g  en, 
table  of,   336 
frequency  of,  334 

statistics  of,  334 
pathology  of,  334 
ph  ysical  examination  in, 

337 
prognosis  in,  341    . 
statistics,    final    results, 

341 
symptoms  of,  336 
treatment  of,  339 
operative,    340 
red  ucti  on  of  deform- 
ity in,  339 
by  plaster  bandage, 

339 
Thomasbracein,340 
removal  of   astrag- 
alus in,  340 
description      of 
operation,  340 
bones  and  joints,  194 
of  elbow  joint,  351 

excision  of  elbow  in,  353 
description     of 
operation,  354 
final  results  of, 
354 
pathology  of,  351 
prognosis  of,  353 
statistics,  age  at   incip- 
iency,    table    of, 
351 
situation  of,  351 
symptoms  of,  351 
treatment  of,  352 
operative,  353 
reduction  of  defor- 
mity in,  352 
Thomas  metiiod 
of,  352 
general  dissemination  of,  203 

by  operation,  203 
of  hip  joint,  221 

abscess  in,  285 

frecpiency  of,  285 
significance  of,  286 
treatment  of,  287 
bv    aspiration, 
"288 


INDEX. 


647 


Tuberculous  disease  of   hip   joint,   treat- 
ment by  incis- 
ion, 288 
b  y     injection, 
288 
actual    lengthening   in, 
238 
shortening  in,  236 
causes  of,  236 
in  the  adult,  285 
amputation  in,  292 
atrophy  in,  234 

Brackett's  observa- 
tions on,  235 
causes  of,  234 
theory   of  Saborin, 

234 
theory   of   Vulpian 
and  Charcot,  234 
changes   in   contour   of 

the  hip,  234 
in  combination,  284 
deformities      incidental 

to,  299 
diagnosis  of,  244 

Rontgen     ray     in, 
247 
distortions  of,  228 

apparent  lengthen- 
ing in,  229 
shortening    in, 
230 
explanation  of,  229 
mechanics  of,  232 
double,  283 

treatment  of,  284 
examination  in,  method 
of,  240 
physical,  240 
excision  of  hip  in,  290 
functional    r  e- 
sults      after, 
290,_  292 
statistics       o  f, 
289,  291 _ 
exploratory    operations 

in,  289 
etiology  of,  224 
general     symptoms    of, 
240 
debility,  240 
fever,  240 
history  of,  240 
in  infancy,  285 
local  signs  of,  244 
measurements  in,  241 
method    of    estimating 
degree  of  dis- 
tortion     in, 
242 
Kingsley's   ta- 
ble, 244 
Lovett's  table, 
242 
of  recording  case  in, 
247 


Tuberculous   disease  of   hip  joint,   other 
deformities     incidental 

to,  299 
pathology  of,  221 

changes      in       the 

joint,  223 
situation  of  disease, 
223 
prognosis  in,  294 

functional  results  of, 
297 
statistics       of, 
297,  298 
mortality,  295 

statistics  of,  295 
progression     of     symp- 
toms in,  249 
reduction   of  deformity 
of,  256,  258' 
by    osteotomy, 

293 
by  plaster  ban- 
dage, -^65 
by         Thomas 

splint,  263 
by         traction 

brace,  256 
by  weight  and 
pulley,  268 
relative     frequency    of, 

196,  197,  224 
retardation  of  growth  in, 
238 
tables  of,   238, 
239 
sinuses  in,  treatment  of, 

289 
statistics  of,  224 

age,  197,^  198.  225 
age  at    incipiency, 

table  of,  225 
of  deformity  in,  248 
sex,  197,  225 
side   affected,    197, 
225 
symfitoms  of,  225 
limp,  226 
night  cry,  226 
pain,  226 
reflex         muscular 

spasm,  227 

stiffness,  227 

treatment  of,  249 

Bradford  frame  in, 

271 
chair  for,  278 
during       convales- 
cence,  280 
splints  for,  280, 
281 
fixation  in,  272 
"high  shoe"  in,  254 
Jiidson's  brace   in, 

255 
lateral  traction  in, 
271 


648 


INDEX. 


Tuberculous   disease   of    hip  joint,  treat- 
ment,   long     hip 
brace  in,  276,  277 
mechanical   princi- 
ples of,  251 
perineal  bands  in, 

254 
Phelps'   hip    brace 

in,  278  _ 
plaster  spica  band- 
age in,  266 
application  of, 
266 
reduction     of    de- 
formity  in,   256, 
263,  268,  293 
"stilting"   in,  273 
Tavlor"  s  braces  for, 

276,  279 
Thomas'  splint   in, 
261 
description  of, 

261  _ 
m  o  d  i  fi  cation 
of,  264 
traction  brace,    va- 
rieties of,  252 
relative    effici- 
ency of,  257 
traction  bracein, 251 
traction,    splinting, 
stilting,   combin- 
ed in,  273 
t  racti  on  straps  in,  253 
of  joints,  synovial  disease,  201 

statistics  of,  201 
of  knee  joint,  304 

abscess  in,  318 

statistics  of,  318 
treatment  of,  318 
bv    aspiration, 

"318 
by  incision,  318 
actual   lengthening  in, 
310 
shortening  in,  310 
amputation  in,  321 
arthrectomy  in,  319 
advantages  of,  319 
results  of,  319 

statistics  of,  319 
table  of  short- 
ening in,  320 
deformity  in,  322 

statistics  of,  322 
diagnosis  of,  310 

differential,  310,311 
etiology  of,  305 
excision  in,  320 

description  of  oper- 
ation, 320 
mechanical  support 

after,  321 
results  of,  321 
selection    of    cases 
for,  320 


Tuberculous  disease  of  knee  joint,  func- 
tional results  of,  322 
statistics  of,  322 
general  conclusions  on, 

323 
mortality  of,  322,  323 
operations  for  relief,  fi- 
nal deformity  of,  321 
pathology  of,  304 
primary  distortions   in, 

307  \ 
prognosis  of,  321 

statistics  of,  321 
retardation    of    growth 
in,  310 
statistics       of, 
310 
secondary  deformities  of, 
308  _ 
statistics       of, 
310 
situation  of,  304 
statistics   of,    304,  305, 
306 
age,  305 
sex,  305 

age   at   incipiency, 
table  of,  306 
symptoms  of,  306 
synovial  disease  in,  318 
treatment     of, 
318 
chloride  of 
zinc   in, 
318 
carbolic 
acid  in, 
205,  318 
i  o  d  o  form 
injection 
in,  319 
venous  sta- 
sis in,  205 
treatment  of,  311 

conservative,  312 
during       convales- 
cence, 317 
forcible    correction 

in,  314 
mechanical,  314 
Thomiis     knee 
brace  in, 
314 
description 
of,  315 
the    caliper 
brace  in, 
317 
description 
of,  317 
reduction     of    de- 
formity   in, 
312 
by  the  plaster 
bandage,  313 
by  traction,  313 


INDEX. 


649 


Tuberculous  disease  of  knee  joint,  reduc- 
tion of,  by  the  Billroth  splint, 
313 
of  shoulder  joint,  348 

abscess  in,  350 
pathology  of,  348 
prognosis  of,  350 
results  of,  350 
statistics,    age     at    in- 
cipiency,     table     of, 
349 
statistics    of    frequency 

of,  348 
symptoms  of,  349 
treatment  of,  350 
operative,  350 
of  spine,  17 

at    cervico-dorsal  junction, 
53 
diiTerential       diag- 
nosis, 54 
complications  of,  87 
abscess,  87 

in  different  regions, 

88 
treatment  of,  89 
deformity  of,  17 
effect  of,  17 
diagnosis  in  general,  57 
etiology  of,  21 
forcible  correction,  deform- 
ity of,  101 
Calot's    opera- 
tion, 101 
statistics,      re- 
sults of,   102 
selection        of 
cases  for,  102 
gradual   correction,  deform- 
ity of,  104 
Metzger-Goldthwait 
apparatus  for,  105 
history  of,  33 
local  paralysis  in,  98 
lower  cervical  region,  52 
lower  region  of,  35 

characteristic    atti- 
tude in,  35 
difTerential  diagno- 
sis of,  41 
increased     lordosis 

in,  35 
lateral    inclination 

of  body  in,  38 
location  of  pain  in, 

38 
pelvic    abscess    in, 
40 
treatment  of,  90 
psoas      contraction 
in,  36 
lumbar,    peculiarities  of  in 

infancy,  44 
middle  region,  46 

abscess  in,  49 
diagnosis  of,  50 


Tuberculous  disease  of  spine,  middle  re- 
gion, symptoms  of, 
48 
treatment  of,  90 
paralysis  in,  93 

duration  of,  95 
statistics    of    frequency 

liability  to,  in  dif- 
ferent regions,  94 
prognosis  of,  95 
time  of  onset  of,  95 
symptoms  of,  95 
treatment  of,  97 
operative,  98 
duration  of,  99 
pathology  of,  18 
physical  signs  of,  34 
principles  of  treatment  of,  80 
prognosis  of,  24 
rational  signs  of,  32 
record  of,  57 
recurrence  of,  100 
regional  examination  in,  35 
secondary  deformities  of,  100 
statistics  of,  21 
age,  22 
frequency,  21 
sex,  22 
situation,  22 
symptoms  of,  24 
diagnostic,  25 
general,  29 
secondary,  28 
treatment  of,  58 

anterior  shoulder  brace 

in,  66 

of  the  different  regions, 

special        indications 

for,  83 

horizontal  fixation  in,  60 

apparatus  for, 

60 
Bradford 
frame,  60 
applica- 
tion of, 
62 
Phelps'  bed,  60 
reel  i  n  a  t  i  o  n- 
gypsbet  t  e  s, 
Lorenz,  for, 
60 
wire    cuirasse, 
60 
jury  mast  in,  73 
mechanical,         general 

principles  of,  58 
plaster  jacket  in,  70 
principles  of,  80 
recumbency,  indications 

for,  81 
Taylor  brace  in,  63 

measurements    for, 

64 
application  of,  64 


650 


INDEX. 


Tuberculous  disease  of  spine,  middle  re- 
gion, Taylor  head  support 
in,  69  _ 
upper  region,  51 

symptoms  of,  52 
Thomas  collar  in,  79 
sub-astragal oid  joint,  339 
diagnosis,  339 

differential,  339 
tarsus,  341 
disease  of  individual  bones, 

statistics  of,  341 
primary    disease    astragalo- 
scaphoid  joint,  342 
prognosis,  342 
statistics    of    situation    of, 

341 
treatment  of,  342 
wrist  joint,  354 

prognosis  of,  355 
statistics  of,  354 
age    at    incip- 
iency,    table 
of,  355 
symptoms  of,  345 
treatment  of,  355 
caries  sicca  in,  201 
connective  tissue  in,  200 
deposit  of  fibrin  in,  200 
diseases  predisposing  to,  195 
etiology  of,  194 
extra-articular,  199 

abscess  in,  199 
local  predisposition  to,   195 
influence  of  injury 
in,  195 
osteophytes  in,  200 
pathology  of,  198 
perforation  of  joint  in,  200 
predisposition  to,  194 
hereditary,  194 
acquired,  194 
prognosis  of,  202 
repair  in,  202 
rice  bodies  in,  201 
seat  of,  196 

secondary  abscess  in,  200 
secondary  changes  in,  200 
septic  infection  in,  202 
statistics  of,  196 
age,  197 

distribution,  196 
relative  frequency,  197 
statistics  of  results  of,  203 
sex,  197 

side  affected,  197 
treatment  of,  204 
by  drugs,  204 
by  local  application,  204 
carbolic    acid, 

205 
iodoform,    204 
venous  stasis,  205 
"  white  swelling  "  in,  201 
teno-synovitis,  347 
Tumor  albus,  see  Tuberculous  Disease  of 

Knee  Joint,  304 
Typhoid  fever,  arthritis  following,  211 


Typhoid  spine,  110 

treatment  of,  110 

I TNILATERAL  coxa  vara,  396 
U     dislocation  of  hip,  378 

genu  valgum,  415 
Upper  extremity,  deformities  of,   in   an- 
terior poliomyelitis,  447 

VALGUS,  traumatic,  624 
Vertebrae,  absence  of,  186 
Vertebral  column,  stifihess  of,  see  Spon- 
dylitis Deformans,  111 
Volkmann's  seat  in  lateral  curvature  of 
spine,  180 

WEAK  foot,  507 
anatomy  of,  508 
in  childhood,  519 

out  and  in  toeing  as  symp- 
toms of,  519 
diagnosis  of,  514 
etiology  of,  511 
extreme  types  of,  517 
pathology  of,  511 
rigid,  527 

treatment  of,  527 
adjuncts  in,  532 

plaster  strapping  in, 
532 
forcible  over-correction 

in,  527 
systematic  manipulation 

in,  527 
Thomas,  532 
symptoms  of,  513 
treatment  of,  521 
attitudes  in,  522 
brace  in,  525 
exercises  in,  523 
treatment,  operative,  532 
the  shoe  in,  521 
support  in,  523 
varieties  of,  516 
Webbed  fingers,  437 

etiology  of,  437 
treatment  of,  437 
Weight,  table  of,  190 
White  swelling,  see  tuberculous  disease 

of  knee  joint,  304 
Willett's  operation  for  calcaneus,  619 
Wire  cuirasse  in  treatment  of  Pott's  dis- 
ease, 60 
Wolff's  law,  190 

method  of   correction  of    confirmed 

club  foot,  593 
treatment  of  genu  valgum,  423 
Wrist,  acute  teno-synovitis  at,  360 
congenital  deformities  at,  434 
joint,  tuberculous  disease  of,  354 
sprain  of,  359 
chronic,  359 

treatment  of,  359 
treatment  of,  359 
subluxation  of,  434 
etiology  of,  434 
treatment  of,  434 
Wry  neck,  see  torticollis,  474 


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RD  731  W59^cT  ^'^^'^'^'^^  '^"'"''^ 

A  ''■eajise  on  orthopaedic  surqer' 


2002306735 


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